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Epithelioma of the Mouth. 



BY 



H. I. Ostrom, M. D. 

Author of "A Treatise on the Breast and its Surgical 
Diseases;" Member of the American Institute 
of Homeopathy ; the Homeopathic Med- 
ical Society of the County of 
Neiv York, etc., etc. 




New York: 
A. L. CHATTERTON COMPANY. 

1885. 



Copyright, 1885, 
H. I. OSTROM, M. D. 



Martin & Niper, 

Printers, Electrotypers and Binder} 

218 Fulton St., Brooklyn, N. Y. 



PREFACE. 



The following monograph is the out growth 
of a series of investigations, entered into in 
the course of professional study, for the 
purpose of elucidating to the author, some 
obscure points in the pathology, ethiology, 
and treatment of epithelioma of the mouth. 
Originally designed for personal use only, 
the notes made, early assumed the character 
of a study of the subject, which, in accord- 
ance with urgent requests, is now presented 
to the profession. 

H. I. OSTEOM. 

139 West 45th St., July, 1885. 



CONTENTS. 



CHAPTER I. 

The Epithelium of the Mouth. 

CHAPTER II. 

Epithelioma of the Mouth. 



CHAPTER I. 
The Epithelium of the Mouth. 

For our present purpose it is convenient 
to study the epithelium of the mouth. 

This will be found to include the lining of 
the buccal cavity, the covering of the tongue, 
and the essential part of all the glands that 
pour their secretions in front of the pharynx. 

Before the fourth week in the life of the 
human embryo, there is developed at the 
lower part of the face a broad, transverse 
cleft. This is the primitive mouth, (strom- 
odocum), and while the initial step in its 
development is a growth inwards of that 
part of the face which corresponds to the 
embryonic depression, the future enlargement 
of the buccal cavity depends more upon the 
growth outwards of the fronto nasal process 
in the middle, the superior maxillary pro- 
cesses on the sides, and the mandibular 
plates, which are continuous with the 
maxillary processes, than upon the extension 
inwards, the deepening of the primitive 
cleft. 



EPITHELIUM OF THE MOUTH 13 

Developed as it is from the face, and 
carrying with, it the covering of the face, 
the investing membrane of the mouth is 
derived from the epiblastic layer of the 
blastoderm. This depression of the epiblast, 
the future mouth, forms a sac, that is at first 
closed posteriorly, having only an anterior 
opening between the processes above men- 
tioned. Not until the eighth or ninth week is 
a communication established between the 
mouth and the pharynx — the latter is of 
mesoblastic origin — by breaking down the 
anterior wall of one cavity, and the posterior 
wall of the other. 

It is thus seen, that the mouth and the 
pharynx are in the embryo, two separate 
non- connecting cavities, the first having its 
origin in the epiblastic layer, the second in 
the hypoblastic layer, and visural mesoblast. 

This embryonic differentiation suggests the 
possibility of a corresponding distinction 
being made between the future functions, of 
these two divisions of the alimentary canal ; 
but also, and especially because of its bearing 
upon the etiology of the diseases of the 
mouth, of establishing a relation between 
the blastodermic layer represented, and the 



14 EPITHELIUM OF THE MOUTH 

form of disease that it develops. It must be 
confessed, however, that this anticipation 
has thus far been only partially realized ; for 
while the differentiation of the embryo into 
layers, and the development of these layers 
into organs and parts with an unchanging 
regularity and exactness, has been demon- 
strated, it cannot at present be shown that, 
for example, the glands of the mouth, and 
the glands of the pharynx, may not develop 
exactly similar diseases, and present indis- 
tinguishable histological conditions. 

The usual method of the development of 
glands — by a prolongation inwards of the 
epithelial layer upon which the secreting 
organ is to open, — renders it probable that 
the mouth, whatever may be its mature con- 
formation, when viewed in its simplest form, 
presents a continuous layer of tissue, with- 
out depressions or elevations ; and that the 
variously formed recesses that constitute the 
salivary and mucous glands, are a later 
development, to meet the requirements of the 
growing organism. 

This anatomical distinction, which marks 
the functionally active mouth, forms two 
convenient divisions for studying the buccal 



EPITHELIUM OF THE MOUTH 15 

epithelium, — the non-glandular, and the 
glandular tissue ; but let it be emphasized 
that they have the same genesis, and that 
their histological distinctions are the 
result of functional requirements. 

The features by which epithelial tissue is 
recognized, are few, but well marked. The 
cells though variously shaped are nucleated, 
and everywhere in close apposition, or are 
held together by a cohesive substance that is 
not always apparent. They are arranged on 
a base of connective tissue — the membrana 
propria, or in the case of glands, the stroma 
— in the form of one or more layers, in which 
there is no vascular system, but in which the 
supply of nerves is sometimes quite abun- 
dant. These layers of epithelial cells 
constantly cover the surface of the body, and 
those canals and cavities that communicate 
with the surface. They may, therefore, be 
looked upon as defining the body, as con- 
stituting a natural boundary to the organism, 
and as everywhere presenting a surface upon 
which contact with external objects is 
effected. 

The definiteness with which epithelial 
tissue, as distinguished from the bodies that 



16 EPITHELIUM OF THE MOUTH 

enter into its construction, is recognized, is 
not found to be equally true of the individual 
epithelial cells, for these, when isolated, are 
not always clearly characteristic ; and 
especially when young and immature, before 
they have assumed either the form or func- 
tion of a special variety, are not distinguish- 
able from other cells while in a transition 
state, or from other varieties of epiblastic 
derivatives. A reason for this exists in the 
fact that epithelial cells are not permanent 
bodies. With peculiar rapidity, they pass 
through their different stages of evolution, 
and do not accomplish their physiological 
perfection until immediately before they are 
destroyed, or thrown off. Hence, it is 
apparent that as one variety of epitkeliuni 
can pass into any other variety, if the con- 
ditions and requirements are favorable for 
such a metamorphosis, it is impossible to 
predict the form that the young cell may 
assume. 

Functionally active epithelial cells are 
not provided with a cell wall, but are 
composed of protoplasm in the form of a fine 
riticulum, in the meshes of which is found 
the peculiar cell contents. The nucleus and 



EPITHELIUM OF THE MOUTH 17 

nuceoli are also composed of a riticulum, 
that is apparently continuous with that of 
the cell body, but the nucleus is constantly 
surrounded by a double contoured limiting 
membrane. Such naked bodies are young 
cells, of which the outer zone of protoplasm 
has not hardened into "formed material," 
to give a protective envelope. 

The contents of epithelial cells will be found 
to vary with their function, and the period of 
functional activity at which they are exam- 
ined, for all epithelial cells a.re secreting bod- 
ies, the nucleus probably possessing an elect- 
ive power over the substance secreted and 
elaborated. 

The non-glandular, or investing epithelium 
of the mouth, which is directly continuous with 
the epithalial covering of the face, belongs to 
the stratified pavement variety. It is composed 
of several layers of differently shaped cells, the 
deeper or attached layer being generally col- 
umnar, while the superficial layer presents 
flattened scales, that slightly overlap each 
other,and are not always provided with nuclei. 
Between these layers may be distinguished 
an intermediate layer of polygonal cells, 
having blunt angles. 



18 EPITHELIUM OF THE MOUTH 

The regeneration of epithelium, a regener- 
ation made necessary by the constant des- 
quamation of the cells of the superficial lay- 
er, always takes place from the deeper layer, 
the cells of which do not lie in immediate 
contact with each other, but are united by 
means of spines and ridges — probably the 
continuation of the reticulum of the cell body 
— which, projecting from the surface of one 
cell, are received in corresponding depressions, 
or upon similar spines of other cells, by 
which means are formed intercellular chan- 
nels. 

These tubes probably constitute a vascular 
system, that of necessity changes with the 
multiplication of the cells, and have no other 
walls than the limitations of the epithelial 
cells. It is not unlikely that nerves also 
occupy these channels. 

Below the columnar epithelial cells, and 
resting upon a layer of loose connective tissue 
that serves to unite the buccal mucous 
membrane to the underlying parts, is the 
corium, a structure made up of connective 
tissue fasciculi and elastic fibres, which give 
rise to papillae, the whole of especial interest 
in the present study, as being the tissue that 



EPITHELIUM OF THE MOUTH 19 

contains and supports the numerous mucous 
glands found in this region. 

The epithelial covering of the tongue and 
soft palate differs somewhat from the strati- 
fied epithelium found on the cheeks, lips 
and hard palate. It accurately invests the 
papillae of the tongue, and the taste buds, 
dipping down between these ; and over the 
circumvallate papillae at the base of the organ 
becomes very thick, entirely concealing the 
minute secondary papillae, that are developed 
from the apex of some of the conical papillae. 

The epithelial covering of the secondary 
papillae is characteristic. Over these eleva- 
tions the epithelium is arranged as a 
separate horny layer, prolonged into pro- 
cesses that extend far beyond the papillae 
that it covers. From this circumstance these 
papillae have been called filiform. 

The epithelial cells of the filiform papillae 
are usually more or less hard, containing 
only a small proportion of protoplasm, and 
frequently no nucleus. As with other epithe- 
lial cells, they are constantly being thrown 
off, and their place supplied from the deeper 
layers. 

The larger portion of the soft palate is 



20 EPITHELIUM OF THE MOUTH 

covered with scaly and stratified epithelium, 
that presents no marked differences from the 
investment of other parts of the mouth ; but 
at the upper portion the epithelium is 
ciliated, and in places columnar. . 

In common with other mucous membranes, 
that which lines the cavity of the mouth is 
constantly bathed with mucous. This secre- 
tion is accomplished either by the investing 
epithelial cells, which elaborate murine 
within their protoplasm, and discharge it, 
probably at the same time, and with the cell 
body either intact or destroyed ; or by 
minute glands situated within the sub-mucosa. 

In reference to the first method, it is to be 
noted that the columnar cells are especially 
concerned with the formation of mucous. 
These cells often become so much distended 
with mucigen that they lose their columnar 
shape and assume the chalice or goblet form, 
by bulging near the free border. At the 
same time the nucleus is found pressed 
against the inner and attached part of the 
cell. From the distended part of the cell, 
when this does not burst, a drop of mucous 
may frequently be seen to exude, which 
increases the peculiar form of the cell. The 



EPITHELIUM OE THE MOUTH 21 

scaly or stratified cells do not, to any extent, 
secrete mucous ; and these occupying the 
most superficial layer of the membrane, it is 
probable that the deeper epithelium of the 
mouth, though columnar, is more especially 
for the purpose of regenerating the outermost 
layer of cells, and of less service in secreting 
mucous ; it is not, however, denied that, 
under certain circumstances, they may per- 
form this office. 

It thus appears that the buccal mucous is 
almost exclusively of glandular manufacture, 
and is to a limited degree only, elaborated 
by the investing epithelium. 

A description of the epithelium of the buccal 
mucous glands would, in a great measure, be a 
repetition of what has been already said con- 
cerning the epithelial investment of the mouth. 
For, as we have seen, to a certain but varying 
degree, all mucous epithelium is glandular, 
that is to say, it performs the function of 
secretion. 

The mucous glands of the mouth are 
minute, compound acinous organs — similar 
to the salivary glands — that are formed by a 
prolongation of the investing epithelium, into 
the sub-mucosa. They are lined with 



22 EPITHELIUM OF THE MOUTH 

columnar cells, which when active, assume 
the chalice shape referred to. 

The glands are situated on the inner side 
of the lips, principally the lower, on the 
cheeks, on the hard and soft palate, beneath 
the lymph follicles at the base of the tongue, 
and behind the lingual V near the papillae 
vallata and foramen caecum. On the inferior 
surface of the tip of the tongue, the glands 
form two elongated patches — the glands of 
Blandin and Nuhn — the ducts of which open 
on each side of the fraenum linguce. 

The ducts of the buccal mucous glands are 
usually very short, and are lined with 
columnar epithelium ; the gland itself is filled, 
rather than lined, with the same variety of 
cells. 

The other glands of the mouth, in the 
function and construction of which epithelial 
cells bear a principal part, are the salivary 
glands. These are arranged in three pairs. 
only two pairs of which are situated in the 
mouth, but the parotid glands are included 
among the buccal glands, because their func- 
tion does not differ essentially from the other 
salivary glands, and, also, because their se- 
cretion is poured into the month, together 



EPITHELIUM OF THE MOUTH 23 



with that from the sub-maxiliary and lingual 



glands. 



The salivary glands belong to the group of 
acinous glands, and in every instance consist 
of a variously branched tube, lined with 
epithelium. The alveoli or terminal branches, 
are lined with large tessellated epithelium, 
and the other part of the tube with columnar 
epithelium. These salivary tubes pass in 
different directions within the interior of the 
gland, and perform an important part of the 
process of secretion. The} 7 are not to be 
confounded with the excretory duct of the 
gland, the office of which is probably 
largely mechanical in assisting the flow of the 
saliva from the gland. The salivary tubes 
are not possessed of muscular fibres. 

In the alveoli of the sub- maxillary and 
sub-lingual glands are found two species of 
epithelial cells. Mucous cells, which are 
large and pyramidal, with their apex towards 
the centre of the alveolus, and their nucleus 
almost in contact with the basement mem- 
brane ; and small, granular, irregular cells, 
united in groups, in the form of crescents, 
that are usually situated at the base of the 
alveolus, when their convexity is against the 



24 EPITHELIUM OF THE MOUTH 

basement membrane, and their concavity is 
occupied by the mucous cells ; some- 
times these crescents are found in the centre 
of the alveolus, between two mucous cells. 

These cells contain a serous albuminous 
fluid, which, mingling with the murine of 
the mucous cells, constitutes saliva. The 
paroted gland contains only serous albumin- 
oid cells, the mucous cells being conspicuously 
absent from this salivary organ. 

The essential elements in the secretion of 
saliva are, as in all glands, the epithelial cells; 
but from the fact that healthy saliva contains 
no morphological elements, it may be asserted 
that neither the mucous nor the serous cells 
of the salivary glands contribute more than 
their contents to the formation of saliva. It 
is not probable that physiologically the cells 
of these glands are destroyed in the process 
of secreting saliva, but rather, that they 
elaborate their peculiar contents, and then 
enter into a state that favors the discharge of 
this elaboration, without the disintegration of 
the cell body. 

The regeneration of salivary glandular 
epithelium is a less active process, than 
the regeneration of the epithelial cells 



EPITHELIUM OF THE MOUTH 25 

that form a part of the secretion of other 
glands, is known to be. In health, therefore, 
the morphology of the salivary cells is more 
accurately described as a multiplication than 
as a regeneration, the latter term conveying an 
impression of cellular loss that does not belong- 
to the secretion of saliva. This fact has an 
important bearing upon the etiology of 
epithelioma, aud will be discussed in its 
appropriate place. 

The multiplication of salivary cells proba- 
bly takes place through almost the entire 
length of the salivary tubes, and the alveoli 
of the acinous gland. The process is believed 
to be associated with the varicose fibrils of the 
columnar cells that lie in contact with the 
membrana propria, into which they project, 
and form alveolar like groups. At least in 
some instances, the proliferation of salivary 
epithelium, is accomplished independently 
of the nucleus of the columnar cells, for the 
nucleus that appears in the new cell seems to 
originate in the cell itself, by a process of free 
cell formation, and not by a division of the 
nucleus of the previously existing morx3ho- 
logical element. 

Passing in review this brief description 



26 EPITHELIUM OF THE MOUTH 

of epithelium, and of epithelium of 
the mouth, we find that epithelial cells, 
especially those that invest the mucous 
membranes, perform the function of secretion, 
and that the arrangement of these cells into 
alveoli, is not. for the purpose of changing 
their function, but to facilitate and increase 
their powers of functional activity. 

It has further been observed that the life cy- 
cle of epithelial cells is quickly completed, and 
ends with the casting off of the cell from the 
surface upon which it is developed ; that in 
many instances, though probably not forming 
an essential part of secretion, the cell, either 
as a broken down body, or with its unity 
undisturbed, is a constant element in 
the secreted fluid ; its presence, however, is 
frequently indicative of a pathological state. 

It has also been observed that the epithelial 
cells of the salivary glands are capable of 
undergoing a process of free cell formation ; 
that the nucleus, which is generally credited 
with a controlling influence over cell division, 
is in this instance, powerless to impart to 
the progeny of the columnar cell, the physio- 
logical function, for which it, the cell, exists ; 
and that, therefore, though the cells so formed 



EPITHELIUM OF THE MOUTH 



27 



may follow a perfectly normal course, their 
genesis renders it possible for them to do 
otherwise. 




CHAPTER II. 
Epithelioma of the Mouth. 

It is characteristic of epithelial neoplasms 
wherever developed, that they resemble in 
the arrangement of their component parts — 
connective tissue and epithelial cells — to a 
greater or less degree, glandular tissue. This 
likeness may in some instances, for example 
in adenoma, be so striking as to give the im- 
pression of a duplicate gland ; and in other 
instances, for example in carcinoma, so 
remote as to present, only in isolated parts, 
the general features of secreting tissue — a 
vascular basement membrane of connection 
tissue, upon which is spread an investment 
of non- vascular epithelial tissue. 

To epithelial neoplasms, and by this is 
understood epithelial tissue that is abnormal 
in genesis, arrangement and function, may 
be attributed a clinical history of the most 
marked malignancy ; a malignancy that seems 
to be in inverse ratio to the resemblance that 
the new growth bears to glandular tissue. 

In seeking the cause of this incompat 



30 EPITHELIOMA OF THE MOUTH 

ibility with the life of an organism, it is not 
satisfactory to attribute the entire sum of 
malignancy to the simple multiplication of 
epithelial cells, either as a primary growth, 
or as a secondary deposit ; neither can so 
much virulence be made to depend upon the 
dissemination through the system of a 
hypothetical poison that is manufactured in 
a particular cell area — the epithelial neo- 
plasm. But if to this variety of the tumor 
disease, we apply the principles of rational 
pathology ; of a pathology that has its 
genesis in physiology, and that finds in 
normal operations, the prototype of 
abnormal operations, though still having 
much to explain, we establish our investiga- 
tions upon ascertained laws, and will learn 
that as all vital phenomena are related, and 
because in every instance health must proceed 
disease, life antedate death, the malignancy 
that accompanies a particular histogenesis, 
is the result, either of an increase or a 
decrease of the function of the part or tissue 
effected, and not dependent upon a super- 
added vital process. 

An examination of the function of 
epithelial cells, furnishes an insight 



EPITHELIOMA OF THE MOUTH 31 

into at least one of the causes of their 
marked malignancy when their function is 
perverted. Thus, the office of epithelial cells, 
especially the columnar investing epithelium 
of the mucous membrane, and of the secreting 
glands, is to extract from the blood a 
peculiar pabulum. 

In certain proportions this pabulum is 
physiological in the blood, but if it falls 
below, or rises above the limits of a normal 
quantity, it is evident that we have to deal 
with a more or less pernicious alteration of 
the nutrient fluid. Now if by the numerical 
increase of epithelial cells — a constant con- 
dition of the growth of epithelioma — the 
functional activity of that particular cell 
area is augmented, either the blood is 
deprived of some of its constituents, or some 
manufacturing organ is called upon to main- 
tain its normal standard. Is there not in 
this found an explanation of the cachexy 
that follows the development of epithelioma; 
of the malnutrition, and wasting of tissues 
that do not appear until the epithelial cells, 
the gland cells, have multiplied beyond their 
normal number ; until the function of second- 
arily effected glands, as when the lymphatics 



32 EPITHELIOMA OF THE MOUTH 

become implicated, is so altered as to 
convert the lymphatic gland into one that 
resembles the organ primarily diseased. 

But this is not the only effect of the 
multiplication of epithelial cells, for it 
becomes evident that these cells, while they 
appropriate more pabulum than should be 
removed from the blood, are also capable, by 
virtue of their glandular endowment, of 
originating an entirely new and abnormal 
secreting function, the performance of which 
not only represents a process of removing 
from the blood elements that form a part of 
its normal composition, but also a manufac- 
turing process, by which the elements 
secreted by the abnormal glands cells, are 
by them elaborated and returned to the sys- 
tem in a condition, harmful, if not poisonous. 
In this sense a neoplasm may be said to owe 
its malignancy to a peculiar poison, but the 
possibility of such a poison is one of the 
closing features of a series of phenomena, 
that if they are not sufficient to cause the 
distraction of the organism, certainly reduce 
vitality to such a degree, as to render the 
system unable to resist even slightly adverse 
conditions. 



EPITHELIOMA OF THE MOUTH 33 

Epithelioma of the month has its origin in 
the epithelial cells, either of the mucous 
membrane, the mucous glands, or the salivary 
glands. 

Two distinct initial processes are observed 
in the development of epithelioma of the oral 
mucous membrane. The more highly malig- 
nant form, first appears in the substance of the 
investing membrane, as a nodule of epithelial 
cells. From the centre of this nodule the 
ulceration proceeds outwards, the more 
superficial layers of tissue being gradually 
involved in the process of destruction. The 
extension of the nodular variety of epithelio- 
ma is not confined to the superficial tissues, 
but is essentially an infiltrating growth that 
involves contiguous structures. 

From the primary nodule, processes com- 
posed of the same epithelial .cells, project 
into the sub-mucosa, until finally this struc- 
ture is occupied in every direction by the 
same carcinomatous mass. The neoplasm is 
further enlarged by separate nodules uniting. 
These deeper parts may join in the ulceration 
process, and then give rise to excavations in 
the centre of the epithelioma, from which 
may sometimes be pressed a yellowish, 



34 EPITHELIOMA OF THE MOUTH 

cheesy mass, composed of broken down 
epithelial cells, and cells that have passed 
into a state of fatty degeneration. 

All of the carcinomatous tissue is not 
included in the destructive process of ulcer- 
ation, but there constantly exists a shell of 
>epitnelial cells, hard and closely packed, 
more or less supported ux^on a stroma of 
connective tissue, which forms the indurated 
base so characteristic of epithelioma. The 
stroma upon which the outer zone of carcinoma 
cells rests, and that supports the collections 
of epithelial cells that occupy the parenchyma 
of the neoplasm, is sometimes embryonic, 
partaking of a sarcomatous character. Such 
a mixed histology marks a superlative degree 
of malignancy. 

The ulceration of an epithelioma shows no 
disposition to develop cicatricial tissue, even 
though a temporary scab is formed. Neither 
is there observed the contraction that consti- 
tutes a feature of other ulcerations, the entire 
process is one of the destruction of existing 
tissues, without reconstruction ; of the sub- 
stitution of erratic for normal morphology. 

The other and more benign variety of 
epithelioma of the mucous membrane of the 



EPITHELIOMA OF THE MOUTH 35 

mouth, begins on the surface of the epithelial 
layer, as a crack, or at first, as a simple 
abrasion, that later ulcerates, the ulceration 
extending superficially and never involving 
the deeper structures. Sometimes a small 
soft wart, is the first lesion observed ; but 
probably that condition is generally, if not 
always, preceded by a slight fissure, the 
irritation of which is sufficient to cause such 
a proliferation of epithelial cells, as would 
form a condyloma. 

The initial lesion, from its apparent 
insignificance, is easily overlooked by both 
patient and surgeon. 

Excepting for the depth of tissue involved, 
the two varieties of mucous epithelioma of 
the mouth are with difficulty distinguished, 
after ulceration has become well developed. 
There is the same zone of induration sur- 
rounding both processes ; the same spread- 
ing ulcer ; the same healthy tissue beyond 
the sharply defined, hardened border, and 
the same enlargement of the lymphatic and 
salivary glands. The diagnosis will rest 
principally on the early history of the case, 
and on the degree of rapidity with which 
it reaches a fatal termination. 



36 EPITHELIOMA OF THE MOUTH 

Any of the minute tubular glands of the 
mucous membrane of the mouth may be the 
seat of epithelioma, and it seems probable, 
that occasionally the nodular variety of 
mucous epithelioma arises in these structures. 

By a process of proliferation, the secreting 
cells soon occupy the interior of the gland 
and its excretory duct, converting the organ 
into a solid mass of epithelial cells. The 
morbid process being communicated to the 
superficial epithelium by means of the open- 
ing of the gland, or a ''catalytic action" 
taking place, ulceration follows as in the 
nodular variet}^ of mucous epithelioma. 
Epithelioma of the mucous glands possesses 
marked malignancy ; and it is apparent that 
the situation of the invaded organ, in the loose 
connective tissue, offers peculiar advantages 
for the infiltration of contiguous structures. 

Epithelioma of the salivary glands begins 
as a proliferation of the columnar epithelium 
of an isolated nodule. Other parts of the 
gland are soon involved, and the process 
spreading outwards, both deep and super- 
ficial ulceration supervenes. The rjrocess of 
destruction, however, generally belongs to 
the later stages of the disease. 



EPITHELIOMA OF THE MOUTH 37 

The tumor is at no time well defined from 
the connective tissue in which the salivary 
gland lies ; and the stroma of the neoplasm 
becomes either embryonic, or, from inflam- 
mation excited by the epithelial cells, entirely 
disappears, as the neoplastic process pro- 
gresses. 

It is, therefore, not unusual for epitheli- 
oma of the salivary glands to present a mixed 
histology. The connective tissue stroma 
may be replaced by sarcomatous tissue, which 
becomes incorporated into the tumor, form- 
ing a net- work between the groups of epithe- 
lial cells. As with the epithelioma of the 
mucous glands that show this mixed minute 
anatomy, the salivary epitheliomata are 
highly malignant. 

It is also observed, agreeable to the two 
sets of cells found in the salivary glands, 
that mucoid elements may be mingled with 
the characteristic epithelial cells of the 
neoplasm. This arrangement has not been 
seen in epithelioma of the parotid gland, 
because of the absence of mucoid cells from 
that organ. 

The minute anatomy of epithelioma of the 
mouth, shows in every direction, the distin- 



38 EPITHELIOMA OF THE MOUTH 

guishing features of pavement epithelioma 
generally. 

To the naked eye the tumor presents a 
grey or rose tinted appearance. On section, 
the mass is found to be of unequal consist- 
ence, and to be made up of dense collections 
of epithelial cells, arranged in concentric 
layers that resemble the leavf s of an onion. 
Between these bird-nest bodies a less dense 
connective tissue stroma lies, that may 
exhibit in different parts almost any degree 
of development. In this stroma, the arteries, 
veins and capillaries pass, but are never 
continued into the epithelial tissue. 

It will thus be seen that there is little in 
the individual cells of epithelioma when 
isolated, to determine the nature of their 
genesis. Normal epithelial cells, when func- 
tionally active, or when subjected to pres- 
sure, assume various shapes : it is, therefore, 
the arrangement of these elements that must 
be looked upon as bearing a principal part 
in the neoplasm ; and their relation to the 
connective tissue, that anatomically distin- 
guishes epithelial, from connective tissue 
neoplasms. 

If the section of the abnormally proliferat- 



EPITHELIOMA OE THE MOUTH 39 

ing epithelium is made to extend through 
the matrix of the growth, it will be found 
that there is no absolute dividing line between 
the tissues, save in their arrangement, and 
that this peculiar arrangement of epithelial 
and connective tissue, becomes less marked 
towards the periphery of the mass, passing 
by imperceptible gradation, into healthy 
tissue. 

The absence of a limiting membrane to 
epithelial neoplasms, is the chief cause of 
their invasion of neighboring structures, and 
of the infection of lymphatic glands. 

Though, as we have seen, any part of the 
epithelial lining of the mouth may become 
the starting point of epithelioma, this neo- 
plastic disease shows a preference for certain 
locations, to the almost entire exclusion of 
others. 

As a primary disease, epithelioma of the 
mouth is rarely developed in other locations 
than the lips, the gums, the salivary glands, 
the tongue, and the palate. The tonsil? 
the cheeks, and the floor of the 
mouth, are generally attacked secondarily, 
or by direct continuity of tissue. 

The reasons for the immunity enjoyed by 



40 EPITHELIOMA OF THE MOUTH 

some parts of the mouth, and the susceptibility 
shown by others, is not always discoverable. 
If we receive mechanical or chemical injuries 
as etiological factors, and we certainly are 
not justified in excluding either, there is 
found a class of exciting causes of epithelioma 
of the lips, gums, and anterior part of 
the tongue ; but the entire mouth is subject 
to much the same kind and degree of trauma, 
with the different results named ; there must, 
therefore, be other etiological factors, that 
either alone or in conjunction with traumatic 
causes, are powerful to excite a local neo- 
plastic process. I am inclined to believe 
that the principal factor in the etiology of 
epithelioma of the mouth, will be found to 
relate to the peculiar kind and degree of 
functional activity of the minute mucous 
glands situated in the region affected. The 
theory that epithelioma owes its origin 
to a perverted glandular function — not neces- 
sarily of a secreting organ, but generally so, 
because there the glandular function is 
intensified — has elsewhere been referred to, 
and there is no reason for excluding the 
present variety of epithelioma from that 
hypothesis. 



EPITHELIOMA OF THE MOUTH 41 

The labial glands, for example, are much 
more abundant in the lower than in the 
upper lip, and are generally entirely absent 
from the angles of the mouth. ]N"ow it is 
exactly where the labial glands are the most 
plentifully developed, at the junction of the 
mucous membrane with the skin, and on the 
free border of the lower lip between the 
median line and the angle of the mouth, that 
epithelioma of the lip is usually developed. 
1 do not remember to have seen any cases 
reported in Avhich the neoplastic process 
began in the angle of the lips, nor have I 
met with such examples in my own practice. 
In the upper lip epithelioma is so rare, that 
its existence has been denied. 

The lingual glands are distributed at the 
root of the tongue, on the sides and at its 
apex, and it is in these situations that epi- 
thelioma is most frequently developed. The 
same relation is found between epithelioma 
and the glands of the palate and uvula ; in 
the latter part the mucous glands are very 
large. 

An exception to the glandular origin of 
oral epithelioma may seem to exist, when 
this neoplasm is developed from the gums ; 



42 EPITHELIOMA OF THE MOUTH 

but upon investigation, we find that columnar 
epithelial cells are largely concerned in the 
construction of the investing epithelium of 
the gums and alveoli, and we have already 
observed that columnar cells are in a peculiar 
manner capable of assuming the function of 
mucous glands. 

While, therefore, columnar epithelial cells 
form a part of the oral mucous membrane 
generally, it is probable that the etiological 
factor of mechanical irritation, enters with 
force in the localization in the gums, of 
epithelioma. For here irritation is very 
likely to arise from a decayed or ragged 
tooth, and from the presence between and 
around the teeth of decomposed food, or to 
follow the attempt to remove such collections 
of effete matter. 

It is possible that derangement of the 
digestive organs may exert some influence 
over the development of oral epithelioma, 
though the degree of this influence cannot 
be told. Cases however occur, in which 
chronic gastritis and dyspepsia rjrecede the 
development of epithelioma of the mouth. 
If these circumstances stand in the relation 
of cause and effect to each other, it is rjrob- 



EPITHELIOMA OF THE MOUTH 43 

able that the oral epithelium is excited, or 
possibly only irritated — the initial lesion — 
by the long-continued acid of effete matter 
or other risings from the stomach. 

The clinical history of epithelioma shows 
the development of this neoplasm to be 
associated with the period of physical decay; 
to the time of life when the organism as a 
unit, and in its individual parts, is beginning* 
to disintegrate, beginning to offer less resist- 
ance to its environment, and to -enter upon 
that process of equilibration, that in its per- 
fection results in dissolution, and the re- 
establishment of organisms. 

I have elsewhere (A Treatise on the Breast 
and its Surgical Diseases) referred to the 
probable connection between the upfolding 
of the mammary glandular function, and the 
development of epithelioma ; the same rela- 
tion probably exists between the involution 
of all epithelial structures and their path- 
ology. 

The mammary gland being x3hysiologically 
subject to oft repeated periods of evolution 
and involution, may naturally be expected 
to illustrate this hypothesis in a marked 
degree ; but the transitory nature of epithe- 



44 EPITHELIOMA OE THE MOUTH 

Hum generally, at once suggests that a similar 
relation may obtain between epithelial neo- 
plasms wherever developed, and the meta- 
morphoses that accompany the natural death 
and desquamation of all epithelial bodies. 

It is thus shown to be the age of the 
individual unit rather than the aggregation 
of units — unless these bear a definite relation 
to each other — that determines the develop>- 
ment of epithelioma generally, and therefore, 
of the mouth. It is however true, that 
physiologically, all secreting organs, even 
those that, unlike the mammary gland and 
ovaries are not subject to a final complete 
involution, become less active with advancing 
years ; and that the secreting cells — the 
epithelial cells — pass into a condition of fatty 
degeneration and vacuolation during the 
process of upfolding, and as their function 
becomes less vigorous. 

The glands that enter actively into the 
process of digestion, are notably effected by 
the senile period. The salivary glands be- 
come less active, and may continue at a very 
low degree of functional activity for a length 
of time ; this same imperfect glandular oper- 
ation, is prolific of neoplastic processes, par- 



EPITHELIOMA OF THE MOUTH 45 

ticularly of epithelioma. Many of the gland 
cells become at the folding np process, or low 
degree of functional activity, waste cells, 
bodies intended to be thrown off from the 
system, but if these are not removed from 
the gland, a circumstance that frequently 
occurs, being endowed with epithelial powers 
of regeneration, perverted, however, they 
form a center for pathological cell prolifera- 
tion. In this sense, epithelioma of the mouth, 
is a disease of declining years, because to 
declining years belong certain histological 
changes that per se favor the development 
of this neoplastic disease. 

But it is evident, that no period can be 
named, during which epithelioma must de- 
velop ; for individuals differ, as much in the 
rapidity with which they pass through their 
several stages toward maturity, and then re- 
verse the process, as they do in physiognomy, 
or mental qualities ; and while it is still true 
that epithelioma is a disease of decay one 
organism may mature, be maintained, and 
decline, in a much shorter period than is 
consumed by another organism. I am there- 
fore inclined to regard the development of 
epithelioma in adolescence, as indicating a 



46 EPITHELIOMA OF THE MOUTH 

premature general or local decay ; a folding 
up of some process, before its natural time 
of involution. 

With a better understanding of the genesis, 
histology, and chemical history of epithelio- 
ma, it becomes more evident that the disease 
in its first stages, is a purely local disorder, 
and not, as formerly believed, and still held 
by a few eminent surgeons, the out-growth 
of a constitutional state. 

As a proof of the local origin of epithelio- 
ma, it is only necessary to remember that the 
neoplasm appears, — is indeed, usually dis- 
covered quite by accident — , in jDersons who 
enjoy excellent health. Before the neoplasm 
is observed, there are no indications of the 
approach of the future disease, and it is not 
until after the development of the local mal- 
ady, and the development of secondary neo- 
plasms, that the system suffers ; that the 
peculiar cachectic appearance that belongs 
to epithelioma, makes itself manifest. The 
involvement of the system, in some instances 
follows so rapidly upon the development of 
the primary neoplasm, as to lead to the im- 
pression that the general disease preceded 
the local, but if such cases are examined care- 



EPITHELIOMA OF THE MOUTH 47 

fully, and their previous history analyzed, it 
will be found otherwise. 

The results of the removal of an epithelio- 
ma in its earliest recognizable stage, also 
speaks in favor of a local origin ; for the 
neoplasm will not return, if the operation is 
performed before secondary nodules develop ; 
and prior to the lymphatics being involved 
in the morbid process. 

The constitutional origin of epithelio- 
ma,— all that is here said of epithelioma 
generally, applies to epithelioma of the 
mouth with equal force — , and the necessary 
inheritance and transmission of the neo- 
plastic disease, are closely related theories, 
and must fall together. 

That epithelioma, or auy other peculiar 
and pathological histo-genesis, to which an 
organism has become so far accustomed, as 
to tolerate its existence, may be transmitted 
to an offspring, in the same manner in which 
a characteristic feature or entirely physio- 
logical distinction are given, admits of no 
question ; but that such a genesis is essential 
to the development of a pathological condi- 
tion, any more than it would be to a physio- 
logical condition, does not appear, from what 
is known of biology. 



48 EPITHELIOMA OF THE MOUTH 

The son may resemble his ancestors' phys- 
iology, and pathology, or he may not, the 
determining factor in either case, being un- 
known. Or again, the child may present 
peculiarities of structure, physical or moral 
deformities, that cannot be traced to any 
progenitor. 

There is no reason for excluding such 
phenomena from the realm of the redistrib- 
ution, and rearrangement of force and mat- 
ter, in which vital changes constantly have 
their origin. In this domain, belongs the 
variation that makes the individual ; that 
makes the son, though an outgrowth of his 
father, differ from him. 

While therefore a pathological histogene- 
sis may be transmitted from parent to off- 
spring, its appearance in the child, does not 
involve a belief in heredity, nor does it 
contradict, the de noro origin of the change. 

The etiology, as well as the pathology of 
epithelioma will become clearer, the more 
our investigations are directed towards normal 
methods, as the prototype of abnormal meth- 
ods ;the closer we acknowledge to be the rela- 
tionship between health and disease. We 
will then see that one, is the continuation of 



EPITHELIOMA OF THE LIP 49 

the other ; that both processes are vital phe- 
nomena, and subject to the same laws ; that 
in health there is a general gradual establish- 
ing of an equilibrium between the organism 
and its environment ; that in disease there is 
in isolated parts, a premature like result, 
that finds its motive power in an increase or 
decrease, of functional activity. 

Epithelioma oftlielij?^ begins as a small, 
hard, painful nodule, situated immediately 
beneath the superficial layer olepithelium, at 
the junction of mucous membrane and skin. 
The neoplasm therefore has its rise in the 
columnar cells that cover the papilla, or as 
has already been suggested, in the epithelium 
ofthe labial glands. 

Tin:; primary nodule increases in size by a 
more or less rapid proliferation of the epithe- 
lial cells, and soon sends processes into the 
underlying connective tissue. As the de v eper 
structures become involved, ulceration always 
takes place. At first the destruction of tissue 
is superficial,but the process soon spreads, and 
a deep, uneven, granulating excavating is de- 
veloped, over which is formed a constantly 
renewed blackish gray scab. The edges of 
the ulcer are somewhat overhanging, and 



50 EPITHELIOMA OF THE MOUTH 

present the hard, almost cartilaginous con- 
sistence, that characterizes all epithelioma- 
tous ulcers. 

The destruction caused by epithelioma of 
the lip, is principally in the direction of the 
superficial structure, or more strictly, the 
ulceration of both deep and superficial 
tissues, proceeds together. 

In the earlier stages of the neoplasm, the 
abnormal histogenesis is confined to the 
epithelial tissue, but as this becomes more 
removed from healthy growth, the neighbor- 
ing connective tissue cells are excited to pro- 
liferate, and there ensues an area of embry- 
onal connective tissue cells, that surrounds 
the epithelial nodule. 

Epithelioma of the lip, is not to be ranked 
among the rapidly developing forms of this 
neoplasm. Its first stages are rather slow, 
and are not clearly defined. The enlarge- 
ment of the sub-maxillary and cervical 
glands, does not occur until the primary 
nodule has become well devekrped, and the 
diagnosis may be obscured by the superficial 
scab, which not being removed, jn'events a 
knowledge of the extent of the underlying 
destructive ulceration. 



EPITHELIOMA OF THE LIP 51 

The disease with which epithelioma of the 
lip, is most likely to be confounded, is the 
primary lesion of syphilis, the occurrence 
of which in the mouth, there is reason to 
believe is increasing in frequency in this 
country. The history of the case, wiU how- 
ever generally prove sufficient for a diagno- 
sis, when a not very well defined case is 
rendered more obscure, by denying the possi- 
bility of infection. 

Epithelioma of the lip, is a disease of ad- 
vancing life ; chancre is generally found in 
youth. 

Epithelioma of the li|3, is almost confined 
to the lower lip ; chancre is confined to no 
locality. 

Epithelioma of the lip is usually developed 
in men ; chancre of the lip is usually found 
in women. 

The glands in epithelioma of the lip, are 
not involved until quite late in the disease ; 
in chancre of the lip, they begin to enlarge 
before the second month of the disease. 

The ulcer of epithelioma of the lip, has a 
Hat bottom, with overhanging, clearly, de- 
fined edges ; the ulcerated chancre is more 
of an excoriation, and when the tissue is lost, 



52 EPITHELIOMA OF THE MOUTH 

the excavation is funnel shaped, the edges 
shelving to the base of the ulcer. 

The scab is a constant feature of epithel- 
ioma of the lip, and its characteristic appear- 
ance has been described ; chancre of the lip 
does not always form a scab, and when the 
process takes place, it is imperfect, the cov- 
ering of the sore being thin, and easily 
removed. 

Epithelioma of the lip, is usually attended 
with severe burning pain : chancre of the lip, 
as in other situations, causes little, if any 
suffering. 

The two diseases can be further differenti- 
ated by applying the test of the microscope. 
In one case is found the characteristic ar- 
rangement of non-vascular epithelial cells. 
and vascular connective tissue, the epithelial 
cells occupying the histological position of be- 
ing the primarily effected bodies ; in the other 
case, epithelial tissue occupies a most sub- 
ordinate position, the lesion consisting almost 
entirely of embryonal connective tissue, in 
which the vessels are large, and numerous. 
The microscope also shows the discharge from 
epithelioma to be made up of broken down 
epithelial cells, and the discharge from a 



EPITHELIOMA OF THE LIP 53 

chancre, to consist of pus corpuscles, blood 
and serum. 

Epithelioma of the lip, sometimes closely 
resembles a lupus ulcer, or lupus exedens, 
but the history and pathology of the two 
diseases are entirely dissimilar, and when 
examined, will be sufficient to establish a 
diagnosis. 

Epithelioma belongs to late life ; lupus to 
youth, being rare after the thirty-fifth year, 
and most frequent about the sixteenth year. 

Epithelioma of the lip is more frequent in 
men ; lupus is more frequent is women. 

Epithelioma is rare in the upper lip ; lupus 
is rare in the lower lip. 

The border of epithelioma has been de- 
scribed ; the border of lupus is not generally 
infiltrated, nor are the lymphatic glands 
enlarged. 

Examination shows the corium to be the 
seat of lupus ; the neoplasm is therefore of 
connective tissue genesis, any epithelial cells 
that are found may be considered as quite 
accidental to the disease. 

The ulceration that accompanies epitheli- 
oma of the lip, may be so extensive as to 
destroy the labial muscles ; and the patho* 



54 EPITHELIOMA OF THE MOUTH 

logical action set up so powerful, as to pro- 
duce most serious nutritive change, in the 
maxillary bones. 

The etiology of epithelioma of the lip, is 
believed to include the local irritation caused 
by the use of a pipe. It is very true that 
many persons who use tobacco in this way, 
suffer from ejjithelioma, but on the other 
hand many do not, for the disease is very 
rare in the East, where both men and women 
smoke pipes. I am inclined to think, that if 
smoking has any value, considered as a cause 
of epithelioma, it is the heat of the pipe stem, 
that produces local irritation. In eastern 
countries, the mouth-piece used, is removed 
some distance from the part of the hookah 
that contains the tobacco, and does not become 
at all heated ; to this circumstance, we may 
possibly attribute the immunity from epithel- 
ioma of the lip, that is enjoyed by Orientals. 

Epithelioma of the lip, however, occurs in 
men who do not smoke a pipe, or use tobacco 
in any form, this therefore can be regarded 
as but one of the causes of the disease ; other 
causes may be any irritant, that acting upon 
the labial glands, or mucous membrane, ex- 
cites their epithelium to proliferate, or the 



EPITHELIOMA OF THE LIP 55 

same result may follow a purely local over 
nutrition of the parts. 

The average duration of life of persons 
suffering with epithelioma of the lip, if the 
disease is allowed to progress unmolested, is 
about eighteen months, but in no form of 
epithelioma, may a cure more reasonably be 
expected to follow operative treatment, than 
the one now under consideration, it must 
however be understood, that such favorable 
results can be obtained, only when the oper- 
ation is performed in the early development 
of the neoplasm, while it is still a local cell 
derangement. If treatment is delayed until 
secondary nodules develop, and the sub- 
maxillary glands are participating in the 
morbid process, no operation of lesser mag- 
nitude than to include all the diseased tissues, 
will avail to arrest the progress of the malady; 
it is obvious that such an operation would 
be impracticable, therefore any treatment 
that may be adopted, after the infiltration of 
tissues has begun, must be palliative. Remov- 
al of the primary nodule may be considered 
advisable even at a late day, but the disease 
is thereby, only arrested, and one centre of 
infection destroyed. In a few months, or 



56 EPITHELIOMA OF THE MOUTH 

before the cicatricle tissue has formed, the 
neoplasm will develop either in the neigh- 
boring glands, or at the seat of the primary 
tumor. There is reason to believe that con- 
siderable infiltration from the local neoplasm 
into the lymphatic glands, sometimes takes 
place before these glands show any sign of 
disease ; the absorbed epithelial cells remain- 
ing inactive, until conditions favorable to 
their proliferation obtain. It may thus 
occur, that after the removal of an epitheli- 
oma of the lip that was considered a local 
disease, the cervical glands soon develop the 
same morbid histogenesis ; such a result may 
be looked npon as proof of early cell infil- 
tration, and may be received in favor of a 
timely operation. 

Thus far, I have spoken entirely in favor 
of the knife, in the treatment of epithelioma 
of the lip, because I believe it to be the most 
certain means of curing this particular form 
of epithelioma, when the treatment can be 
commenced early in the course of the disease. 

Prom the use of caustics, or any other 
treatment, applied for the purpose of de- 
stroying the neoplastic cells, I have never, 
in a case that I would be willing to pronounce 



EPITHELIOMA OF THE LIP 57 

epithelioma, witnessed a cure. I am aware 
that other surgeons, whose opinion commands 
respect, report better results than I have 
seen, or obtained, from the use of such con- 
servative methods. I may have been unfor- 
tunate in the selection of my cases. 

Aside from the clinical results, I cannot 
but look upon the principle of treatment as 
unscientific, when a more rapid, and certain 
method exists in the knife. It is acknowl- 
edged that the disease must be removed ; to 
accomplish this with an escharotic, requires 
many applications, and necessarily consumes 
valuable time. A constant feature of the 
treatment, is a certain degree of inflamma- 
tion in the neoplasm and its matrix, a path- 
ological condition, that by rendering absorp- 
tion more active, is calculated to defeat the 
object of the treatment. 

If in the surgeons judgment a. part must 
be removed, let the operation be performed 
as speedily as the safety of the patient, and 
thoroughness, will permit ; always remem- 
bering that a make-shift cannot occupy a 
place in the scientific surgeons equipment. 

With the use of toxical applications of 
medicinal substances, I have not had much 



5S EPITHELIOMA OF THE MOUTH 

experience. Hydrastis, in the form of the 
powdered root, made into a poultice, com- 
bined with the internal use of the triturated 
drug, is highly recommended. Phytolacca, 
applied after the same method, is also well 
spoken of. Conium. locally and internally, 
has in my hands greatly relieved the pain 
of epithelioma of the lip, but I have come to 
rely chiefly on the Iodide of Calcarea, to mit- 
igate the suffering in these cases. Antim- 
erud, Arsenic, Clematis, Asafcetida, and 
Ranunc-bulb, may be found indicated. Es- 
pecially the latter remedy, used locally and 
internally, seems to have effected some cures 
of labial epithelioma. 

The operation for the removal of an epith- 
elioma of the lip, is very simple. 

When a general anaesthetic is used, I 
prefer chloroform, which if carefully admin- 
istered, — the respiration should be observed, 
not the pulse, — need not complicate the 
danger of the operation. Sufficient local 
insensibility however can be induced, with 
the Hydro chlorate Cocoaine. 

An assistant compresses one side of the 
lip between his thumb and index finger, 
beyond the line of the proposed incision^ 



EPITHELIOMA OF THE LIP 59 

while the surgeon compresses the opposite 
side, for the double purpose of controling 
the labial arteries, and of steadying the lip 
while lie transfixes it below the tumor. By 
cutting towards the free border of the lip, 
the first incision is made. Entering the 
knife at the point of transfixion, the second 
incision is accomplished by again cutting 
towards the free border of the lip, in such a 
direction as to include the tumor in a Y 
shaped mass of tissue. The knife should in 
no instance touch the neoplasm, but should 
constantly be made to cut through healthy 
structures. 

The hemorrhage, which is sometimes quite 
profusf when compression of the lip is re- 
moved, is generally control ed by bringing 
the cut surfaces together. 

Before closing the wound, it is well to 
wash the edges of the flaps with a solution of 
the chloride of zinc, to destroy any wander- 
ing infectious epithelial cells, that may 
remain. 

For the purpose of holding the flaps in 
contact, I prefer to use one pin at the ver- 
milion border of the lip, and many silver 
sutures in the remaining part of the wound. 



60 EPITHELIOMA OF THE MOUTH 

Much care is required to maintain the line of 
the lip, and it is to better accomplish this 
that I introduce the single pin, over which 
silver wire that has been previously oiled, to 
facilitate its removal, is wound in the form 
of the figure eight. 

The silver sutures should be passed through 
the entire thickness of the lip, and if the 
tension on the tissues is very great, they 
should be reinforced with strips of adhesive 
plaster. 

The dressing of the wound consists of a 
sublimated cotton compress, and a bandage 
about the head and face. 

At the end of the second or third day, the 
wound should be examined, and if x^ossible, 
the sutures removed, to avoid the scars that 
may follow, if they are allowed to remain 
too long. In all cases after removing the 
sutures, adhesive plaster should be applied 
for several days, until the union seems per- 
fectly firm. 

For use during the operation, and to 
cleanse the sponges and hands of the surgeon 
and his assistants, the bichloride of mercury, 
1-1000, will be found very satisfactory. It 
is a perfect antiseptic, and free from danger, 
if used in this strength. 



EPITHELIOMA OF THE GUMS 61 

Epithelioma oT the gums, is at first an 
essentially superficial lesion. There is no 
tumor, and no swelling of the effected parts, 
until the disease is well advanced ; neither 
does pain form a constant or marked feature 
of the neoplasm. 

The disease begins as an apparently simple 
abrasion, a crack, of the investing epithelium 
of the gums. The initial lesion may be situ- 
ated at the border of the alveolus, or where 
the mucous membrane is reflected upon itself 
at the angle formed by the floor of the mouth 
and the inferior maxilla, for epithelioma of 
the gums as a primary disease, is most fre- 
quently developed in the lower jaw. 

From the slight, scarcely noticeable abra- 
sion, there soon develops a ragged ulcer, 
with the characteristic indurated border of 
epithelioma. The ulcer, if beginning on the 
inner side of the gum, spreads towards the 
tongue, but if the abrasion has its seat on 
the outer side, the cheek is soon involved ; 
more rarely, the ulcer spreads across the gum, 
to involve both tongue and cheek. 

The destruction of tissue that begins in 
epithelioma of the gums, is only limited by 
the distribution of epithelial cells, and if not 



02 EPITHELIOMA OE THE MOUTH 

arrested, the tongue, the palate, the pharynx, 
the entire epithelial lining, may become im- 
plicated, producing a vast ulcerated surface, 
that interferes with deglutition, and renders 
speech difficult, if not. impossible. The 
almost cartilage like hardness of the floor of 
the ulcer, causes great stiffness of the parts, 
and the sharp burning pains, that increase as 
the disease spreads, renders life a prolonged 
misery. 

The suffering is augmented by the quan- 
tity and fetor of the discharge, which is 
expectorated with such difficulty, that the 
patients is soon exhausted ; and also by the 
enlargement of the salivary, and cervical 
lymphatic glands, which become very pain- 
ful. 

Histologically, it is impossible for the 
maxillary bone to become converted into a 
part of an epithelial neoplasm, for cellular 
substitution does not extend beyond the 
limits of a tissue series. Those cases of 
epithelioma, in which the maxillary bones, 
beyond the lining of the alveolar cavity 
become diseased, or destroyed, are instances, 
not of the connective tissue cells becoming 
epithelial cells, but first, of the invasion of 



EPITHELIOMA OF THE GUMS 63 

the bony structure by epithelial bodies, and 
second, of the inflammatory new formation 
of connective tissue cells, and the consequent 
development of embryonal bodies. 

The general diagnostic features of epithe- 
lioma of the mucous membrane, will usually 
serve to distinguish the disease from other 
ulcerations of the gums, and investing epith- 
elium of the mouth. The mature age of 
the patient ; the hardness of the base of the 
ulcer ; the implication of the absorbents ; 
the characteristic pain, and the tendency of 
the ulcer to spread rapidly in every direc- 
tion, present a picture sufficiently clear to 
form a diagnosis of epithelioma, but if doubt 
remains, the microscope will determine the 
nature of the disease. 

A section of epithelioma, shows the char- 
acteristic epithelial and connective tissue 
arrangement, and that the discharge consists 
of broken down epithelial cells ; a section of 
any other variety of ulceration that is likely 
to be confounded with epithelioma, shows 
an absence of epithelial tissue, and that the 
disease belongs to the connective tissue neo- 
plasms. 

The causes of epithelioma of the gums, 



04 EPITHELIOMA OE THE MOUTH 

may usually be traced to some local irrita- 
tion, or injury. A broken or ulcerated rooth. 
or an injury to the gum induced by using a 
stiff tooth-brush, or tooth-pick, are quire 
sufficient to excite a local ej 

. that may result in a neoplasm, if the 
parts are in the stage of legeneration, that 

ieds and nies the develop] 

- epithelial 
Epithelioma of the gums, and this is here 
made to include all the = :ial epithelial 

.tions. that originating in the gum. 
involve more or less of the buccal mucous 
: : very amenable to medical 
treatment. 

There are a few remedies however, that 
administered internally, and applied locally, 
— for I believe the latter emphasizes the 
action of a di ig — . offer some hope, that the 

se can be cured without the aid of the 
knife. Foremost among these I would place 
Ranunculus hvXbosus. The provings of the 
:_:;._. show a marked similarity between the 
pathological effects, and an ulcerating epith- 

a : and while I cannot report a ca 
cure. I feel confident that the pi gross of the 
ulceration has been arrested, and that the 



EPITHELIOMA OF THE GUMS. 65 

neoplastic histogenesis has been controled 
by its use. Equal parts of the fluid extract 
and glycerine, should be brushed over the 
ulcer daily, and the first trituration adminis- 
tered internally. 

Phytolacca, has received favorable men- 
tion, for the treatment of epithelioma of the 
mouth. 

Galium aperinum is also accredited with 
curative properties, in epithelioma of the 
mouth. 

In one case, of most rapidly destructive 
epithelioma, that began near the last lower 
molar tooth, and spreading backwards in- 
volved the pharynx, I succeeded in arresting 
for a time, the destruction, by daily applica- 
tion of the Chloride of Chromium. In all 
these cases, the surgeou labors under the 
disadvantage of being consulted too late, and 
therefore it is impossible to say what the 
effect of treatment would be, if applied early 
in the history of the disease. 

From the nature and position of the tissues 
attacked, after the disease has become exten- 
sive, any operation to be effective, would 
involve formidable mutilation. While the 
disease is confined to the region of the jaw, 



66 EPITHELIOMA OF THE MOUTH. 

even after the alveoli and bone are involved, 
a section of the maxilla, or the entire removal 
of the bone, may be made with the possible 
effect of preventing a return of the neoplasm ; 
but when the disease has invaded the larynx, 
it is questionable surgery to remove that 
organ. The operation may prolong life, but 
it is a severe procedure, and the statistics of 
the few cases in which it has been performed 
for epithelioma, are not encouraging, either 
in the immediate, or remote results. It is 
quite certain, that when epithelioma has 
invaded the larynx, it has also infiltrated 
other parts, usually the cervical lymphatics, 
and each one of these glands may become 
the center for a new development of the 
disease. 

If therefore, epithelioma of the gum can- 
not be operated upon, while still the disease 
is local, even though the structures involved 
are extensive, provided they are confined to 
the cavity of the mouth, it is well to with- 
hold the use of the knife, and depend uj)on 
pharmacology for a cure. 

It may be possible to arrest the progress 
of the disease by the actual cautery, or the 
nitrite of silver, but I have seen only tern- 



EPITHELIOMA OF THE GUMS. 67 

porary relief follow such applications, and 
have thought that the resulting reaction, 
had the effect of exciting the neoplastic 
process to fresh activity. 

Unless the neoplasm is very large, and 
involves much of the lower jaw, it will not 
be necessary to incise the lower lip to effect 
a removal of the diseased structures. By 
freely dividing the mucous membrane be- 
tween the gum and the lip, the growth can 
be easily removed, with Liston's heavy cross- 
cutting bone forceps. But if the diseased 
structures cannot be so excised, the surgeon 
must not hesitate to perform the more exten- 
sive operation, of removal of the jaw. 

Operations about the mouth, are very 
likely to be complicated by blood flowing 
into the larynx and embarrassing respiration. 
To avoid this, and to do away with the use 
of Trendelenburg' s laryngeal tampon, a rather 
cumbersome apparatus that does not always 
prove satisfactory, and the practice of per- 
forming tracheotomy as a preliminary opera- 
tion, and then packing the larynx with 
sponges, Prof. Annandale has suggested 
the feasibility of allowing the patient's head 
to hang over the edge of the table. His 



68 EPITHELIOMA OF THE MOUTH. 

method deserves warm commendation, for 
not only does the dependent position of the 
head afford natural drainage of the mouth, 
but by not interfering with respiration, ren- 
ders tracheotomy unnecessary. Though the 
tongue falls back towards the pharynx after 
division of the genio-glossus muscles, the 
epiglottis is not closed, and breathing con- 
tinues to be perfectly easy. 

To remove half of the lower jaw, it will be 
found convenient to extend the incision 
along the margin of the bone, from the lobe 
of the ear, to the median line. If necessary 
to further expose the bone, a vertical incision 
through the lip, may be made to join the 
first incision. After securing the facial 
artery, the cheek is dissected from the jaw, 
to an extent required by the tissue to be 
removed, taking care to avoid wounding the 
facial nerve. After extracting a tooth at the 
point where the bone is to be divided, the 
latter oi3eration may be performed with a 
small straight-backed saw, or with the chain 
saw, which I prefer for this purpose. By 
now seizing the bone with the "lion-forceps," 
it may be drawn out, and allow room to run 
the knife along its inner surface, keeping 



EPITHELIOMA OE THE GUMS. 69 

close to the bone, to avoid wounding the sub- 
maxillary gland and lingual nerve. After 
dividing the pterygoid muscle, traction on 
the bone will depress the coronoid process, 
so that the temporal muscle is easily sepera- 
ted from its attachment. If now the knife is 
passed in front of the joint, dislocation will 
readily be accomplished, and by cautiously 
cutting behind the bone, the latter may be 
wrenched from the face. It is important at 
this stage of the operation, to exercise the 
utmost gentleness, for the condyle and neck 
of the maxilla are easily forced against the 
internal maxillary artery, to injure which, 
would unnecessarily complicate the opera- 
tion. 

The after treatment, as well as the opera- 
tion, should be conducted upon strict anti- 
septic principles. For this purpose, I prefer 
the bichloride of mercury, 1-1000. Before 
closing the wound, it is well, as recommended 
by Mr. Christopher Heath, to apply the 
actual cautery to the cut surface of the bone, 
for the purpose of removing rough pieces, 
and of arresting any oozing that may take 
place. 

The drainage tubes being in position, and 



70 EPITHELIOMA OF THE MOUTH 

their placing is a matter of the first import- 
ance, the wound should be dusted with 
iodoform, which has a specific action upon 
the healing of bone, and the flaps brought 
together with both deep and superficial 
silver sutures. Over the wound, carrying 
out the principle of a dry dressing, which I 
believe to be the true antiseptic dressing, is 
placed a large compress of sublimated cotton, 
and the whole secured with the usual head 
and face bandage. 

Without disturbing the dressing, the 
mouth should be frequently cleansed with 
a solution of chloride of zinc, thirty grains, 
to one ounce of water; or of permanganate 
of potassium, about 1-1000. 

In the place of the sublimated cotton, it 
may be well to dress the wound internally 
and externally, with iodoform gauze, as 
suggested and practiced by Prof. Billroth at 
his clinic in Vienna. His success in opera- 
tions about the mucous passages, is almost 
phenomenal, and should stimulate other 
surgeons, to obtain like results with the 
methods he employs. 

The dressing should not be disturbed, 
unless symptoms of inflammation develop, 



EPITHELIOMA OF THE GUMS. 71 

before the eighth day, when the wound will 
be found to have so far healed, as to make 
removal of the sutures and drainage tubes 
safe. 

The use of a mechanical appliance to pre- 
vent the contraction of the muscles of the 
remaining portion of the jaw, is probably of 
doubtful propriety. For it has been found 
almost impossible to so keep the bone in 
position, and the pain caused by any appar- 
atus thus far devised, is sometimes intense, 
and cannot be endured. If left to natural 
processes, the parts will adapt themselves to 
their new relations, better than when art 
interposes, to produce certain results. 

Epithelioma of the upper gum is rarely a 
primary disease, but usually secondary to 
the development of the neoplasm in the 
antrum. In this cavity, squamous epithe- 
lioma develops to an alarming extent, before 
its presence is suspected, or with only such 
swelling of the face, and illy defined pains, 
as may be attributed to neuralgia, or an 
ulcerated tooth. Indeed the trouble is fre- 
quently believed to be an ulcerated tooth, 
and the supposed diseased tooth extracted. 
The true nature of the disease is then made 



72 EPITHELIOMA OF THE MOUTH 

evident, by the destruction of the floor of 
the antrum, and the subsequent protrusion 
of the epithelial mass through the alveolus. 

Or epithelioma may be mistaken for an 
abscess of the antrum, and the existence of a 
neoplasm not diagnosed, until the antrum 
wall is punctured, for the evacuation of the 
supposed pus. 

Before the conditions are present, favor- 
able for a microscopic examination, the age 
of the patient is the most important factor in 
deciding the nature of the disease. Swelling 
and pain of the superior maxilla, occurring 
in a person over fifty years of age, would 
lead to a suspicion, of grave and malignant 
disease of the antrum. 

Unfortunately the age of those suffering 
from epithelioma of the antrum, is opposed 
to the success of so grave an operation as the 
removal of the superior maxillary bone ; but 
the rapidity with which the disease invades 
the deeper structures, places the only chance 
of relief, iu the most active, and thorough 
extirpation of the neoplasm ; and this means 
nothing less than removal of the superior 
maxillary bone. 

The removal of the superior maxilla, is 



EPITHELIOMA OF THE GUMS. 73 

best accomplished by following the line of 
incision suggested by Sir. Wm. Fergnsson. 

To expose the bone sufficiently for its ex- 
cision, and at the same time to avoid the 
unsightly scar and contraction that remain 
after destroying the angle of the mouth, 
which necessarily divides the facial nerve, 
as proposed by Mr. John Lizars the first 
surgeon to demonstrate the possibility of 
removing the entire superior maxillary bone, 
Sir. Wm. Fergusson carried the incision 
through the median line of the lip, into the 
nostril, and if necessary, prolonged the in- 
cision up the side of the nose, to end in a 
curve under the orbit, that terminated at its 
outer angle. Besides the advantages of this 
incision, already mentioned, the extent of 
the mutilation may be regulated by the judg- 
ment of the surgeon, as he proceeds with 
the operation. 

After freeing the ala, and dissecting up 
the tissues that form the lower flap, the in- 
cisor teeth of the bone to be removed are 
extracted, and the alveolus and hard palate 
divided with a straight narrow saw, passed 
through the nostril. The same instrument 
begins a division of the nasal process of the 



74 EPITHELIOMA OF THE XOrTH 

superior maxilla, and the malar bone, that is 
completed with the bone forceps. The bone 
is now seized with the "lion-forceps.*' and 
separated from the palate bone, and ptery- 
goid process. Before laving the knife aside, 
the infra-orbital nerve is divided, and the 
soft palate severed of its attachment to the 
bone. 

After arresting hemorrhage with animal 
ligatures, and the actual cautery, which 
should always be used, and when all oozing 
has ceased, the parts are to be dusted with 
iodoform, and the flaps brought together 
with hare-lip pins, and silver sutures. 

In adjusting the severed lip, the utmost 
care should be observed to maintain the line 
of the vermilion border. As. in the operation 
for hare-lip. contraction may take place, it is 
sometimes well to curve the border of the 
flap, and so lengthen the line of the incision. 
The same dressing and after treatment are to 
be used, as recommended for excision of the 
lower jaw. For the pain and shock that fol- 
low this operation, no remedy will be found 
of greater service than Hypericum* but to 
obtain the best results, it must be adminis- 
tered in drop doses of the tincture. 



EPITHELIOMA OF THE PALATE. 75 

Primary epithelioma of the palate, is 
a very rare disease. The seat of the neo- 
plasm is usually in the antrum, the floor of 
which being destroyed, permits the epithe- 
lial mass to occupy the palate. 

When epithelioma is a primary disease in 
the roof of the mouth, it probably developes 
in the mucous glands of this region. 

The first evidence of the neoplasm is a 
small hard tumor, situated beneath the 
mucous membrane, to which it seems adher- 
ent. The tumor shows the same disposition 
to ulcerate, that marks epithelioma in other 
parts of the mouth, and the ulcer presents 
the usual characteristics of epithelial neo- 
plasms. The pain extends to the face and 
head, and the cervical glands participate in 
the neoplastic process. 

Histologically, primary epithelioma of the 
palate, is probably always a mixed neoplasm, 
containing epithelial, and connective tissue 
cells. When a secondary development, it par- 
takes of the nature of squamous epithelioma, 
resembling in its anatomy, epithelioma of 
the antrum, of which it is a part. 

The medical treatment has been referred 
to ; the surgical treatment will vary with 



76 EPITHELIOMA OF THE MOUTH 

the origin of the disease, and the tissues 
involved. If the neoplasm is developed in 
the antrum, excision of the superior maxilla 
will be necessary, but if it originates in the 
epithelium of the palate, possibly the dis- 
ease can be eradicated by removing as much 
of the bone as the neoplasm involves. If it 
is desired to remove the palate plates of the 
superior maxilla, and of the palate bone, the 
excision may be accomplished, by first ex- 
tracting two of the molar teeth, through the 
alveol of which, access is gained' to the 
cavity of the antrum. With a strong scalpel, 
the integuments covering the palate, are 
then incised down to the bone, in a line cor- 
responding to the floor of the antrum. 

With Liston s bone forceps, curved on the 
flat, or with a small boue chisel, the hard 
palate can then be cut through, in the line of 
the tegumentary incision. If the soft palate 
is not involved in the disease, it can be sev- 
ered from the bone, and allowed to remain. 
The deformity resulting from this operation 
could be overcome by a plate adjusted to form 
an artificial roof to the mouth. I am not 
aware that this operation has before been 
rproposed : anatomically it is correct, piac- 



EPITHELIOMA OF THE TONGUE. 77 

tically it is feasible for diseases that involve 
only the floor of the antrum, and hard palate. 
But it is rare for an epithelioma to be con- 
fined to that part of the maxilla, or to the mu- 
cous membrane of the roof of the mouth. The 
surgeon's efforts to arrest the disease therefore, 
are likely to result in failure, for it is absolute- 
ly necessary, in removing a recurrent 
neoplasm, to cut through perfectly healthy 
tissue. 

Mr. Heath's suggestion, to apply the 
chloride of zinc paste after operating upon 
epithelioma, I have found to be a valuable 
adjunct to the treatment. The paste is to be 
applied on strips of lint, and all possibility 
of its escape into the mouth prevented, by 
careful packing over the lint. The paste 
should not be allowed to remain in the wound 
longer than three days. While the sloughs 
are seperating, I have found nothing better 
then the permanganate of potassium solution, 
with which to syringe the mouth. 

Epithelioma of the tongue, is usually 
a primary neoplasm, it being very rare for 
the disease to spread to that organ, from 
other parts of the buccal mucous membrane. 

The initial forms do not differ from those 



78 EPITHELIOMA OF THE MOUTH 

that mark the first stages of other varieties 
of squamous epithelioma ; but to these two 
forms, the nodule, and the abrasion or fissure, 
there may with propriety be added a third 
initial process, in which the tongue is de- 
nuded of its epithelial covering. The latter 
is interesting, not only because of its com- 
parative rarety, but also because of the 
probability that this pathological condition, 
is but slightly, if at all, removed from 
either the sub-acute, or chronic forms of 
superficial glossitis. In the early stages it is 
impossible to distinguish a case of glossitis, 
— for which disease Schwimmer has suggested 
the name leucoplakia — that is to pursue a 
perfectly benign course, from a case that is 
to terminate in one of the most malignant of 
neoplasms. 

But though these distinct initial forms are 
noticed, there is nothing in the ulcerated 
neoplasm, to indicate the particular process 
in which it began. 

Though epithelioma may develop where 
ever epithelial cells exist, it attacks by pref- 
erence the sides, — especially the right bor- 
der—, the back, and the tip, of the tongue. 
It is possible that the exciting cause of the 



EPITHELIOMA OF THE TONGUE. 79 

disease, determines, to a certain degree, the 
seat of the neoplasm ; and that the part of 
the tongue invaded, influences the course 
that the disease follows. 

The age at which epithelioma of the tongue 
develops, agrees with the jjeriod of life that 
has been found favorable to the genesis of 
this neoplasm in other organs. Epithelioma 
is always a disease of decay, and hence we 
find that its occurrence is most frequent 
between the ages of forty and sixty. 

It is also found, that the majority of cases 
occur in men ; indeed if we exclude from our 
statistics epithelioma of the. uterus and mam- 
mary gland, the male sex is shown to be 
more susceptible of the disease than the 
female sex. It does not appear that physical 
decay is more marked in men than in 
women ; neither are they called upon to 
endure anything that corresponds to the de- 
mands upon nutrition, and physical and 
nervous strength, that belong to the female 
function of reproduction and parturition. 
Perhaps we are nearer an understanding of 
the greater frequency of epithelioma of the 
tongue in men than in women, when we regard 
some of the acquired conditions of life, and 



80 EPITHELIOMA OF THE MOUTH 

constitutions, to which men are preponder- 
ate^ subject. 

Foremost among the former, I place the 
use of stimulants, in the form of tobacco, 
alcohol, and highly seasoned food. As we 
have seen, smoking alone, cannot be con- 
sidered of much importance in the etiology 
of epithelioma of the lip, but I am inclined 
to otherwise regard the habit, in relation to 
epithelioma of the tongue, especially when the 
disease is developed at its apex. Here the 
carbonate and acetate of ammonia, acetic 
and carbolic acid, that are products of the 
dry distillation that accompanies smoking 
tobacco, exert their acrid qualities, and have 
the effect of exciting proliferation of the 
epithelial cells, to protect the under dying 
structures ; or of denuding the tongue of 
its epithelium. 

In a lesser degree, but also contributing to 
the irritation of. the buccal epithelium, and 
adding to the prolonged action of the exces- 
sive use of tobacco, are to be mentioned 
alcohol and highly spiced food, more fre- 
quently used by men than by women. The 
latter fact, may so far contribute to the bane- 
ful effect of smoking, as in a measure it 



EPITHELIOMA OF THE TONGUE 81 

explains the immunity from epithelioma of 
the lips and tongue, that is enjoyed by 
women who so use tobacco. 

Among the constitutions more frequently 
acquired by men than by women, that con- 
tribute to this greater frequency of epithelio- 
ma of the tongue in males, I would assign a 
prominent place to syphilis, especially in its 
secondary stage. 

Any long acting irritation of the epithelium 
of the tongue, is capable of engendering 
genetic changes, that result in an abnormal 
proliferation of the epithelial cells. Such 
conditions exist in superficial secondary 
glossitis, in which there is no ulceration, but 
an erosion, caused by irritating bodies. It 
is not here intended to advance the opinion 
that syphilitic glossitis is an epithelial neo- 
plasm, or that it can become an epithelioma, 
but the belief is expressed, that if to a 
specific glossitis, of the sclerous, not the 
gummatous type, are added the decay and 
cellular degeneration that belong to epi- 
thelioma, local conditions exist that may 
induce the epithelial neoplastic disease. 
Syphilis in itself, causes premature decay, 
and while it cannot be said that this is suffi- 



82 EPITHELIOMA OF THE MOUTH 

cient to bring about such an issue, may not 
the natural decay of the organism, acting in 
connection with disease, exert an influence 
in that direction. 

Beyond age, and sex, the etiology of 
epithelioma of the tongue probably includes 
mechanical irritants. Of these, the principal 
one will be found in ragged or broken teeth. 
The disease develops at a time of life, when 
the teeth are more or less unsound, and have 
begun to decay, leaving sharp edges and 
projections, which coming constantly in con- 
tact with the tongue, cause a fissure in that 
organ. The source of irritation continuing, 
an ulcer that frequently becomes epithelio- 
matous, develops. Of course there must be 
other causes than the ragged teeth, in opera- 
tion, for many persons suffer with such a 
condition of their teeth, and do not have 
epithelioma of the tongue. 

Epithelioma of the tongue, is one of the 
most certainly malignant forms under which 
the epithelial disease appears. My own ex- 
perience does not lead me to look upon the 
neoplasm as rapidly destructive of life, if we 
include the earliest recognizable pathological 
lesion within the limits of the disease; but 



EPITHELIOMA OF THE TONGUE. 83 

when the characteristic epithelial neoplastic 
process is established, the fatal termination 
is not far removed; between eleven and twelve 
months, being the average duration of life. 

A section made through epithelioma of the 
tongue, shows under the microscope, the 
same arrangement of epiblastic and mesoblas- 
tic elements, that belongs to epithelioma 
generally. The groups of epithelial cells are 
more or less dense, and the connective tissue 
stroma varies in consistence from embryonic 
tissue, to closely packed fiber cells. Processes 
of the epithelial structure, are seen to project 
into the under-lying muscles of the tongue, 
until finally, the disease having been allowed 
to follow a natural course, the whole tongue 
becomes involved in the neoplasm. The 
covering of the ulcer contains broken-down 
epithelial cells, cells that show their origin 
in their irregular shapes, and in the 
unimportant position occupied by the cell 
nucleus. 

Epithelioma of the tongue that has its 
initial process in the nodular form of the 
disease, is first noticed as a small, sharply 
defined, smooth tumor, usually situated, 
either at the base, or on the sides of the 



S4 EPITHELIOMA OF THE MOUTH 

organ. The knot rests in apparently healthy 
tissue, and is covered by mucous membrane 
that shows no sign of the underlying 
neojxlastie process. The nednle may remain 
in this condition for a variable length of 
time, attracting little attention save :: in an 
increasing sense of stiffness of the ngue, 
and an inability to articulate with accustomed 
ease. In this stage of epithelioma of the 
tongue, almost more than in an thei form 
of epithelioma, is the nrely I : :al nati;: - : 
the disease illustrated. Th- _ : 

indicate that the pathology has extended 
nd the boundary : the dc lule The 
general health is excellent ; the tissues in 
imm-r xmtact with the neoplasm are 

normal, and the lymphatic .lands 
show nc sign of infection. Th: ^t I 

would designate as the quiescent period of 
epithelioma. A period during which the 
epithelial cells, though already started on 
their pathological course neither multiply 
so rapidly as to be forced beyond the 
boundary of the primary nodule, nor de] 
so far from physiological types and arrange- 
ment, as to rx-ri: a leleterious influence 
up::. mi. 



EPITHELIOMA OF THE TONGUE. 85 

The causes that augment this pathological 
process are not always discoverable. They 
may be either, external — mechanical, or 
within the neoplasm, and a part of the 
neoplastic disease ; but being in operation, 
the center of the nodule breaks down. This 
is followed by ulceration of the integument; 
by such an increase of the neoplastic cells as 
to cause their projection in irregular masses, 
into the lingual tissues ; and by an early 
conveyance of the disease to the neighboring 
lymphatics. The ulceration spreads deeply, 
and does not long remain confined to the 
tongue. The edge and base of the ulcer, 
present the usual induration of epithelioma ; 
the discharge becomes profuse and extremely 
offensive, and the burning pain severe, and 
almost constant. 

If this process of destruction is not arrested, 
the enlarged cervical glands so press upon 
the oesophagus, as to interfere with 
deglutition ; and the constant inhalation of 
the effete discharge may induce septic 
pneumonia, which in connection with maras- 
mus, soon brings about a fatal termination. 

Epithelioma of the tongue tJiat begins in 
a crack or fissure, has its most frequent seat 



86 EPITHELIOMA OF THE MOUTH 

at the rip or sides of the organ, and is 
probably almost always located accidentally. 
by an uneven and sharj} process of a tooth, or 
by a wound that has resulted from masticating 
food. 

The fissure is at first insignificant, but 
eventually becomes bounded by a nias^ of 
densely packed epithelial cells, arranged in 
groops that extend into the ad J 
muscular tissue. 

The subsequent course is in a great measure 
a repetition of the nodular form of lingual ep- 
ithelioma. The fissure deepens, and becomes 
more widely spread ; the lymphatic glands 
participate in the neoplastic process, and 
excessive pain, and prostration, bring a 
welcome close to life. 

Epithelioma of the tongue, that has its 
origin in leucoploJxia, j)resents a form of 
neoplasm, less rapid in its course than the 
neoplasms that we have been studying, but 
not less certainly fatal, if unmolested. 

Attention is first directed to a circum- 
scribed, or general sensation of rawness of the 
tongue, noticeable from its persistence, more 
than its severity. The primary lesion is 
usually attributed to a scald or burn, caused 
by some article of food. 



EPITHLEIOMA OF THE TONGUE 87 



If the tongue is examined at this time, there 
are found, generally on the dorsum, one or 
more dark red, smooth patches, that are but 
little if at all, raised above the surrounding 
mucous membrane. Suppuration, or a 
discharge of any kind is not found at this 
stage of the disease. There is no inflamma- 
tion, and there is an absence of induration 
of the under-lying tissues. 

Without necessarily involving more super- 
ficial tissues, as the apparently simple 
"congestion of the epithelial layers" merges 
into a malignant neoplasm, the base and 
borders of this primary lesion become 
indurated ; che hitherto mucous patch breaks 
down, and is covered with cast off epithelial 
cells. The lymphatic glands now show 
evidences of infection, and what has become 
an ulcerated epithelioma, is the seat of severe 
burning, lancinating pains. 

This form of epithelioma, preserves during 
its whole course, certain characteristics that 
point to the primary lesion. It is for 
example, observed, that suppuration is never 
profuse, and is sometimes quite absent ; and 
that the process of destruction do^s not 
involve the deeper structures, but tends to 
spread superficially. 



88 EPITHELIOMA OF THE MOUTH 

If epithelioma can in any of its forms be 
regarded as a chronic neoplasm, the variety 
that we are now studying is above all others, 
deserving of that position in pathology. The 
process of destruction may gradually increase 
during an almost indefinite length of time, 
before there is to be detected either lymphatic 
infection, or constitutional involvement ; and 
even often these features indicate the nature 
and dissemination of the neoplastic cells, the 
malignancy of the disease is neither as well 
marked, nor as rapidly developed, as has 
been observed in other forms of epithelioma. 

A consideration of the frequency with 
which leucoplakia precedes the development 
of epithelioma of the tongue, is suggestive of 
an analogy between this primary lesion, and 
Paget' s disease of the nipple, in its relation 
to epithelioma of the mammary gland. I 
cannot consider the latter disease a variety 
of eczema, but I am inclined to look upon it 
as an epithelial neoplasm, and as much the 
same process in the nipple, as the leucoplakia 
that precedes epithelioma, is in the mucous 
membrane of the tongue. 

The diagnosis of epithelioma of the tongue, 
is likely to be embarrassed, principally in the 



EPITHELIOMA OF THE TONGUE 89 

direction of secondary and tertiary lesions, 
of that organ. 

The primary sore, and the secondary 
mucous papule of syphilis, can with ordinary 
care be eliminated from the question of 
diagnosis ; but not so with the late secondary 
infiltration, and ulceration, and the tertiary 
gummata. 

As a general distinguishing feature of all 
specfic lesions, it will be remembered that 
enlargement of the lymphatic glands takes 
place early in the course of the disease ; this 
fact, unless the question pertains to one of 
the more rapidly malignant forms of 
epithelioma, will at once suggest the nature 
of the neoplasm. The age of the patient, 
and the usual absence of pain, will also speak 
in favor of a venereal taint. 

The superficial syphilitic lesion, may some 
times present an appearance that is very 
similar to a superficial epithelioma ; but 
in the floor of the former, there are frequently 
developed cracks and fissures, which success- 
ively heal and open, many times ; there is 
also a tendency for the ulceration to spread 
in one direction while healing in another, 
both of which processes, indicate a power of 



90 EPITHELIOMA OE THE MOUTH 

recuperation, that does not belong to 
epithelioma. 

The diagnosis between the ulcerated 
gurnmata. and an ulcerated epithelioma that 
originated in a nodule, is established with 
less ease. After duly weighing the matters 
of age. sex. lymphatic complication, and the 
condition of the surrounding tissues, the 
distinction will rest principally upon the 
appearance of the lesion. 

From the bottom of an ulcerated gumma, 
which is usually deep, and as if scooped 
out. there is more or less sloughing of 
tissue. — a condition that does not obtain in 
epithelioma, the surface of which is covered 
only with broken dowu cells — , and the edges 
are soft, undermined, and somewhat turned 
in upon themselves, thus showing the base 
of the ulcer to be more extensive than the 
tegumentary lesion. 

When however, any doubt exists as to the 
true nature of the disease, a section of the 
neoplasm should be subjected to a micro- 
scopic examination, which may be relied 
upon to confirm the diagnosis. 

Treatment. The success of any method of 
treating epithelioma of the tongue, will in a 



EPITHELIOMA OF THE TONGUE 91 

measure depend upon the particular form 
that the disease assumes, but will more 
especially be influenced by the period at 
which the case comes under treatment. 

The medical treatment that has already 
been suggested for epithelioma in other 
parts of the mouth, may with equal propriety 
be repeated in this place. 

Especial mention may be made in favor of 
gallum aperinum, for epithelioma of the 
tongue ; and I would also direct attention to 
the comocladia dentata, which produces an 
ulcer, characterized by hard indurated edges, 
and covered with a foul discharge. 

But while it may be possible that medicines 
are able to cure an epithelioma of the tongue,. 
in view of the insidious nature of the disease, 
and the finally rapid development of consti- 
tutional symptoms, and secondary neoplasms,, 
the question, how long is the surgeon justified 
in trusting to the action of medicine, before 
he removes the diseased part from the 
organism, becomes one of serious import. 

We are here dealing with a disease, the 
initial process of which is local, but a disease 
that with characteristic rapidity pervades the 
entire system, and multiplies itself in remote 



92 EPITHELIOMA OE THE MOUTH 

parts. If therefore, a case of epithelioma is 
subjected to treatment, while it is a local 
neoplasm, shall we give medicine, or shall 
we, without delay, remove the tumor. Mod- 
ern surgeons almost unanimously speak in 
favor of the latter course ; but there may be 
obstacles in the way of its adoption. First : 
To make the operation thorough, it will not be 
sufficient to remove the nodule of disease 
only, the larger "portion of the tongue must be 
amputated. The inconvenience to the 
patient of the loss of his tongue, needs no 
demonstration. There will therefore be a 
natural desire to preserve the tongue, and a 
disinclination to at once, resort to an opera- 
tion ; but against the loss of the tongue, we 
can place the final loss of life, if the disease 
spreads beyond its local origin. 

Then there is to be encountered the possi- 
bility of a mistaken diagnosis, before the 
development of those very constitutional 
symptoms that render the results of any 
method of treatment doubtful. Of course 
the tongue would not be amputated on the 
supposition that epithelioma was the disease, 
and we have therefore now to decide what 
treatment to pursue, in a case of more or less 



EPITHELIOMA OF THE TONGUE 9£ 

ulcerated epithelioma, that may occur before 
the system suffers. It is difficult to find 
another answer than that just given; the 
uncertainty of medicine, probably arising 
from our ignorance, and the valuable time 
lost in awaiting its action on one hand ; on 
the other hand, the certainty that life will at 
least be prolonged by an operation, — an anal- 
ysis of 54 cases operated on, gives an average 
duration of life of 19 months ; and an average 
of 49 cases not operated on, an average of 
11-7 months, showing a gain for operating 
of 1-6 months. {Arthur E. Baker, Holmes 
System of Surgery — ,) furnish support, to. the 
more active and heroic course of treatment. 

The position therefore of medicine, in the 
treatment of epithelioma of the tongue, 
seems to be limited to those cases that, either 
from the extent to which the tissues are 
involved in the neoplasm, or from some indi- 
vidual reason, cannot be operated on. The 
treatment is then palliative ; happily it may- 
be curative. 

It is now quite generally conceded, that 
the development in the tongue of an obstinate 
ulcer with an indurated base, in a person 
over fifty years of age is sufficient to excite 



94 EPITHELIOMA OF THE MOUTH 

grave suspicions of an epithelioma, and if no 
improvement follows one or two weeks of 
medical treatment, the neoplasm should be 
removed without further delay. In these 
cases, the question is frequently not one of a 
cure, for unless every neoplastic center is 
excised, the disease will return, but resolves 
itself into affording temporary relief, and 
prolonging life. 

"We are now brought to a consideration of 
the third principal obstacle to the excision of 
the tongue for epithelioma, — the mortality 
after the operation : but this one, like the 
former two, will be found to grow less 
formidable, when compared with the 
death-rate that belongs to non-interference ; 
and when the after-treatment, is more 
successful in combating the results of an 
operation. 

The mortality after amputation of the 
tongue has reached the high figure of 
twenty-six per cent, but with improved 
methods of meeting the principal source of 
danger after this operation, — septic pneu- 
monia — , the ratio has greatly decreased, for 
in seventeen cases operated on at Prof. 
Billroth' s Klinik, there did not occur a 
single death. 



EPITHELIOMA OF THE TONGUE 95 

The operation is not a particularly severe 
one, and involves no organ that is essential 
to life. The loss of blood need not be more 
than trifling, and hence the conclusion is 
reached, that the results of the operation 
will depend upon the ease with which the 
lungs become infiltrated with septic matter, or 
irritated with the foul gases from the wound ; 
and this will increase with the nearness of 
the operation to the base of the tongue, and 
the perfectness with which the after treat- 
ment of the wound, overcomes these dangers. 

Various methods have been proposed for 
excising, and amputating the tongue; for rea- 
sons already mentioned, the more extensive 
operation will be most frequently called for 
when the disease is epithelioma, and therefore 
will especially engage our attention in this 
place. 

The operations for amputating the tongue, 
differ principally in the manner of gaining 
access to the mouth, and in the instruments 
used to divide the organ ; the selection will 
be made in accordance with the location of 
the disease, and the extent of tissue involved. 
"The propriety however, of removing all 
diseased tissue, together with the lymphatic 



96 EPITHELIOMA OF THE MOUTH 

glands at the root of the tongue, and in the 
floor of the month, whether they show 
evidence of disease or not. when the neoplasm 
is epithelioma, will also influence the plan 
made for each operation. 

We may discard the older operation of 
Roux, modified by Billroth and V. Langen- 
beck. of gaining access to the tongue by 
dividing the lower jaw. as an unnecessary 
mutilation, excelling when the _t plasm 
involves the gums and bony struct 1 ;: — 
and even then it may be questioned whether 
for such an extensive legeneratdon, any 
operation could be justified — . for the entire 
floor of the mouth can be cleaned out. :_ 1 
the tongue removed at its base, without 
injuring the bone, a grave complication of 
any operation, and one likely to increase the 
danger of septicaimia. 

As the simplest operation that is consistent 
with thoroughness will give the best 
its, it is desirable if possible, to remove 
the tongue through the mouth, without 
making any preliminary incisions. Thi 
be accomplished even when the disease is 
situated at the base of the tongue. 

A gag, that of Westmorland is a useful 



EPITHELIOMA OF THE TONGUE 97 

instrument, is first introduced to hold the 
jaws open. A strong whip-cord is then 
passed through the tongue, and encharged to 
an assistant, with directions to draw the organ 
well forward, as soon as freed from its 
anterior attachments, which constitutes the 
next step in the operation. With a pair of 
scissors, the mucous membrane, and genio- 
hyoglossi muscles are then divided near the 
jaw, thus leaving the tongue attached only 
to the hyoid bone. The scissors may now be 
laid aside, and the twisted wire cord, which 
I find easier to apply than a whip cord, from 
the fact that it better retains any angle to 
which it may be bent, of a not too heavy 
ecraseur, passed behind the seat of disease, 
where it is held by needles that have been 
made to transfix the tongue for that purpose, 
before the chain of the ecraseur was adjusted. 
If before beginning to tighten the instru- 
ment, it is found that the previous dissection 
of the floor of the mouth has not been 
sufficient to allow the chain to cut behind 
the diseased tissues, the tongue can be further 
freed, by tearing its posterior attachments 
with the fingers, or by the cautious use, of 
blunt scissors. The operation is completed, 



98 EPITHELIOMA OP THE MOUTH 

by slowly working the ecraseur until the 
tongue is cut through. In no operation 
about the tongue, do I find any advantage 
from the use of the galvanic ecraseur. If 
possibly it prevents hemorrhage, this effect 
is more than counterbalanced, by the large 
and foul slough of burned tissue that 
remains after its use, and the danger of 
secondary hemorrhage, when that slough 
separates. Why should the attempt be made, 
to remove one process of cell degeneration, 
by establishing another process. 

Without changing the instrument, if it is 
not desired to amputate the tongue with the 
ecraseur, the operation may be continued with 
the scissors that accomplished the first 
dissection, after the method proposed by Mr. 
Whitehead, 

This surgeon has performed successfully 
the brilliant operation of snipping off the 
tongue with scissors, without previously 
ligating the lingual arteries, or taking any 
other means, to prevent hemorrhage. He calls 
his operation, "the bloodless operation." 
While all surgeons agree upon the merits of 
the procedure, there is not the same unanimity 
of opinion as to its anatomical possibility. 



EPITHELIOMA OF THE TONGUE 99 

The question is one of the hemorrhage that 
attends the operation. Mr. Whitehead says 
it is trifling, while other surgeons who have 
followed his method, say that the hemorrhage 
is most profuse, and only with difficulty 
controled. It is certainly not easy to under- 
stand why severing the lingual artery as near 
its origin from the external carotid, as ampu- 
ation at the base of the tongue must divide it, 
would not be followed by such profuse 
hemorrhage, as to require the application of a 
ligature to the bleeding vessel. Until the 
theory of haemostatics upon which Mr. 
Whitehead bases his method is more fully 
known, it seems probable that the "bloodless 
operation" will not come into general favor 
among surgeons. 

After removing the tongue through the 
mouth, it may be found tliat the disease has 
spread more deeply than could before be 
ascertained, and that it cannot be reached by 
the natural orifice ; the plan first proposed by 
Jaeger, of dividing the cheek, can then be 
adopted. The incision should curve from the 
last molar tooth, and terminate at the angle 
of the mouth. It may be made on both sides 
of the face. Although free access to the 



100 EPITHELIOMA OF THE MOUTH 

tongue is gained by this method, the resulting 
deformity from linear contraction, may, as 
in removal of the superior maxilla, be very 
considerable. 

If the lymphatic at the base of the tongue, 
and in the floor of the mouth, together with 
the salivary glands, are involved in the morbid 
process, their removal cannot be accomplished 
through the mouth, either with ease, or with 
success. Tlie floor of the mouth must then 
be opened from below, and the principal part 
of the operation performed through that 
opening. 

Among many others, three infra-maxillary 
operations have been proposed, that will 
meet most of the cases that require this more 
elaborate operation ; I refer to the methods 
of Prof. Kocher, Prof. Billroth, aud Mr- 
Richard Bar well. 

It will here be convenient to speak of 
tracheotomy, and ligation of the lingual 
arteries as preliminary operations in removal 
of the tongue, for both procedures form 
essential steps in the two first mentioned 
operations. 

Opening the trachea, greatly facilitates 
any operation about the mouth that is likely 



EPITHELIUM OF THE TONGUE 101 

to be attended with hemorrhage, for it 
relieves the operator from the anxiety that 
blood is flowing into the trachea and will 
arrest respiration, and allows him to concen- 
trate his attention on the operation. But I 
believe that in many of the simpler operations, 
it is an unnecessary addition to the already 
considerable surgical risk. Mention has 
already been made of Prof. Annandale's 
method of allowing the patient's head to 
hang over the edge of the table. This will 
be found to sufficiently drain the mouth, 
when the operation for removal of the tongue 
does not include an infra-maxillary incision, 
and is performed upon the anterior part of 
the organ. 

When tracheotomy is performed before 
amputating the tongue, the pharynx is to be 
carefully packed with a soft sponge to which 
is attached a strong cord. The sponge should 
be thoroughly cleansed with a, carbolic 
solution before it is introduced. 

The ligation of the lingual arteries before 
amputating the tongue is a prudent step to 
take, when the disease is extensive, or when 
there is reason to believe that the walls of the 
vessels will not hold a ligature. With the 



102 EPITHELIUM OF THE MOUTH 

lingual arteries secured, the surgeon has 
more freedom in selecting his operation, and 
can use all necessary deliberation in 
examining the diseased tissues. 

The method by which Kocher gains 
access to the buccal cavity, is a severe 
operation, but probably affords a better view 
of the posterior part of the tongue, and floor 
of the mouth, and renders the removal of the 
diseased structures easier, than any 
operation yet proposed. 

Tracheotomy is first performed. An 
incision is then made on the anterior border 
of the sterno-mastoid muscle from a little 
below the lobe of the ear, to the hyoid bone. 
Here an acute angle is formed, and the 
incision continued upwards along the anterior 
belly of the digastric muscle. By turning 
the flap thus made upon the cheek, the 
lingual artery is exposed, and ligated. B} r 
this manoeuvre, the attachment of the tongue, 
and floor of the mouth, are opened to inspec- 
tion, and the removal of all the structures 
that are implicated in the pathological 
process, rendered possible. Kocher performs 
the entire operation under the antiseptic 
spray, and packs the cavity that remains, 



EPITHELIOMA OF THE TONGUE 103 

with Listerian gauze, or a carbolized sponge. 
The wound is not held together with sutures, 
but is allowed to granulate, the discharges 
being received into the absorbent dressing. 
If drainage tubes are introduced into the 
angle of the wound, sufficient drainage could 
be maintained, at the same time that the flaps 
are sutured. The tracheotomy tube is not 
removed until the wound is well healed. 

Billroth' s operation is a modification of 
Rignoir s. He makes a curved incision that 
extends along the lower border of the inferior 
maxilla, from angle to angle of the bone. 
Through this opening, the tongue and dis- 
eased structures, after being freed from their 
anterior attachments, are drawn, and excised. 
But this operation, does not offer the facility 
for thorough work, or for removing the 
tongue at its base, that are given by Kocher's 
method. 

The use of the ecraseur through the infra- 
maxillary incision, possesses some advantages 
over the operation with the knife or scissors, 
that commend its adoption when the 
epithelioma is principally confined to the 
tongue. 

The operation performed and practiced by 



I 4 EPITHELIUM OF THE MOUTH 

Mr. Richard Bar-well, is deserving of especial 
iteration, from the ease with which it 
may be performed, and the a scess :hat has 
attended its - - 

After placing a gag between the teeth, the 
tongue is controled, not drawn ont of the 
month, a point insisted upon by Mr. BarweD, 

eans of a cord passed through the raphe. 
An incision about a quarter of an .inch long, 
is made in the median line, from the hyoid 
bone forward, and often dividing the mylo- 
hyoid muscle, and separating the genio-hyoid 
and genio-hyoglossus muscles from their fel- 

:he root of the tongue is reached. With a 
Edston's needle, the point of which is guided to 
a little beyond the last molar tooth, by the 
forefinger placed in the mouth, a loop of 
thread is carried to the side of the tongue. 
A single thread is in the same manner carried 
to the other side of the tongue. The wire of 
an ecraseur. is then by the last introduced 
thread, carried through the supra-L; i 
incision, to the side of the tongue, and often 
passing across the posterior aspect of the 
organ, is made to emerge at the point of 
entrance, by means of the first introduced 
loop. After attaching the wire to the body 



EPITHELIUM OF THE TONGUE 105 

of the instrument, its exact position may be 
ascertained by passing the finger along the 
dorsum of the tongue. In front of the line 
where the tongue is to be divided, a Liston's 
needle should be passed, to hold the wire in 
place. After the base of the tongue is cut 
through, the tissues that still hold the 
anterior part of the organ, are divided by 
means of the ecraseur, worked through the 
mouth. 

Any one of these four operations for re- 
moving the tongue, give ample room to ex- 
cise the healthy lymphatic glands situated 
in that region, but when the glands become 
the seat of secondary deposits, and thus the 
possibility increases of leaving some diseased 
structures in the mouth, the operation of 
Kocher, will be most satisfactory. 

Upon the treatment after amputation of 
the tongue, much of the success of the oper- 
ation depends. The operation should be 
strictly antiseptic, to which end, my exper- 
ience leads me to speak in favor of the 
bi-chloride of mercury, 1-1000, carbolic acid 
being still retained for use as a spray. I 
have not yet seen any bad effects from the 
use of mercury so prepared, and I find that 



106 EPITHELIOMA OF THE MOUTH 

wounds generally, heal more rapidly, than 
when cleansed with any other antiseptic. 

After the operation, and when all oozing 
has ceased, it may be well to wash the parts 
with a solution of the chloride o± zinc, though 
in many cases this is unnecessary. 

Iodoform makes the best permanent dres- 
sing for operations upon malignant diseases of 
the mouth, that has yet been proposed. The 
parts should be well dusted with the dry 
powder, and then covered, either with the 
adhesive iodoform gauze of Billroth, or 
sublimated cotton. The external wound may 
be treated in the same manner. 

Both the internal and external dressings 
should remain undisturbed, as long as the 
character of the discharge, and condition of 
the patient, render it safe to delay interfer- 
ence. One of the advantages of a preliminary 
tracheotomy, is that this very essential rest 
of the parts is possible, for the patient can 
be sustained by enemata, and respiration is 
carried on through the tracheal tube. 



INDEX. 



PAGE 

Acetic acid, product of tobacco smoke, . 80 

Acquired conditions of life, effect of upon epi- 
thelioma, . . . . 79 
Alcohol, effect of upon the development of epi- 
thelioma, . . . .80 
Ammonia, acetate, and carbonate, products of 

tobacco smoke, . . . 80 

Anaesthetics, preference for in operations, 58 

Annandale's, Prof., position of the patient's 

head during operations, . 67, 101 

Antiseptic method, the necessity of using, 105 

" principles of, . . 69, 70 

" spray, use of in Kocher's operation, 102 

Antrum, abscess of, . . . 72 

" epithelioma of the, . . 71,75 

" diagnosis of epithelioma of the, . 72 

" method of gaining access to the, 76 

Arsenic, use of in epithelioma of the lip, . 58 

Asafcetida, use of in epithelioma of the lip, 58 

Barwell's, Mr. Richard, amputation of the 

tongue, . . . . 100, 104 

Billroth's, Prof., amputation of the tongue, 100, 103' 



108 INDEX. 

Billroth's, Prof., iodoform gauze, . 70 
klinik, ... 94 
" " modification of Roux amputa- 
tion, .... 69 
" Bird nest bodies," in epithelioma, . 38 
Bloodless operation of Mr. Whitehead, 98 

Cachexy, explanation of, . . 31 
Carbolic acid, product of smoke, . 80 
Carbolic acid, use of for spray, . . 105 
Carcinomatous tissue, not all included in the de- 
structive process, . . . 34 
" Catalytic action," ... 36 
CausticSjtreatment of epithelioma of the lip with, 56 
Cautery, use of actual, in epithelioma, . 66 
" use of, before closing the wound, 69 
" use of actual, for hemorrhage, 1\ 
Cervical glands, involvment of in epithelioma 

of the lips, . 50 
Cervical glands, involvment of in epithelioma 

of the palate, ... 75 

Chancre, appearance of, . . . 51 

" discharge from, . . 53 

Cheek, Jaeger's method of dividing, . 99 

Chloride of chromium, use of in epithelioma, 65 

Chloroform, preference for the use of, . 58 

Clematis, the use of in epithelioma of the lip, 58 
Comocladia, the use of in epithelioma of the 

tongue, .... 91 



INDEX. 109 

Condylomata, in the development of epithelioma, 35 
Conium, the use of m epithelioma of the lip, 58 
Connective tissue, the base of glands, . 15 

Constitution, the relation of an acquired, to epi- 
thelioma, . . . . 81 
Contraction, linear, after dividing the cheek, 100 
Corium, relation of, to epithelial cells, . 18 
Drainage, Prof. Annandale's method of, 68 
Drainage tube in Kocher's operation, . 103 
" " position of, . .69 
Dressing, the time for removing, . 70 
Ecraseur, use of the galvanic, . . 98 
" the use of in amputation of the 
tongue, . . . 97, 103 
Embryo, differentiation of the layers of, . 14 
Enemata, the use of to administer food, 106 
Epiblastic layer, . . . .13 
Epithelial cells, . . . 16 
" " effect of numerical increase of, 31,32 
" " contents of, . . 17 
" " nucleus of, . 17 
" " life cycle of, . . 26 
" " metamorphosis of, . 16 
" " physiological function of, 16 
" " shape of normal, . 38 
" " vacuolation of, . . 44 
Epithelial neoplasms, clinical history of, 29 
" " resemblance of to gland- 
ular tissue, . . . .29 



110 INDEX. 

Epithelial tissue, general features of, . 15 

Epithelioma, beginning of, in a fissure, . 35 
" causes that determine the location 

of, ..... 79 

Epithelioma, development of. in adolescence, 45 

development of. in epithelial cells, 7^ 

dividing line of, not well marked, 39 

diagnosis of, . . 35 

discharge from, . . 52 

edges of, ... 90 

of the gams, . . . 61 

of the upper gums. . 71 

indurated base of, . . 34 

inheritance of, . . 47 

local origin of, . . 46 

of the mouth, . . 39 

nodular form of, . . 33 

of the palate, . . 75 

physical decay related to the de- 
velopment of, . . . .45 
Epithelioma, reasons for the immunity enjoyed 

by some parts of the mouth, from, . 40 

Epithelioma, removal, effect of upon, in the 

earliest stages, . . . 47 

Epithelioma of salivary glands, . . 3 7 

, section of, . . 63 

" . squamous, of the antrum, 71 

" , surface of, . . . 60 

" of the tongue, . . 7 7 



INDEX. Ill 

Epithelioma, ulceration of, . . 34 

Epithelium, columnar cells of, may assume the 

function of mucous glands, . 43 

Epithelium, deeper layers, office of the, . 21 

" glandular, . . 15 

" investing of the mouth, . 17 

" regeneration of, . . 18 
" varicose fibrils of columnar cells of, 25 

" vascular system of, . 18 

Etiology of epithelioma, age as a factor in, 44 
" " " functional activity of 

glands as a factor in, . . 40 

Etiology of epithelioma, injuries as a factor in, 40 
" " " derangement of diges- 
tive organs, as a factor in, . . 42 

Etiology of epithelioma, physical decay as a 

factor in, . . . 43 

Fergusson's, Sir W., incision for the removal 

of the superior maxilla, . . 73 

Folding up process, the effect of, upon gland 

cells, .... 45 

Frsenum linguae, . . . .22 

Gag, Westmoreland's, ... 96 

Galium, use of in epithelioma of the gums, 65 

" use of in epithelioma of the tongue, 91 

Glands, the alveoli of, . . . 23 

" " center of epithelioma, . 66 

" " development of, . . 14 



112 INDEX. 

Glands, the digestive, effect of senile period upon, 44 
" " ducts of mucous, . . 22 
" " earl)- infiltration of . 56 
" " excretory duct of, . . 23 
" " mucous, the formation of, . 21 
" mucous, the lining of, . . 22 
" the situation of 3 . . 22 
" salivary, . . . 14, 22 
" tubular, the seat of epithelioma, . 36 
Glossitis, superficial, the relation of, to epithe- 
lioma of the tongue, . . 73, 81 
Gummata, diagnosis of, from epithelioma of 

the tongue, .... 90 
Gums, causes of epithelioma of, . 63 
" diagnosis of epithelioma of. . 63 
" epithelioma of the, . . 61 
epithelioma of the upper, . . 71 
" floor of epithelioma of the, . 62 
" operations for the removal of epitheli- 
oma of the, .... 67 
Gums, treatment of epithelioma of the, 64 
Health, establishment of equilibrium in, . 49 
Heath, Mr. Christopher, on the use of the ac- 
tual cautery, . . . 69 
Heath, Mr. Christopher, on the use of the 

chloride of zinc paste, . . 77 

Hemorrhage, in amputation of the tongue, 99 

Histogenesis, transmission of a pathological, 48 
Hookah, the use of in the East, 



INDEX. 113 

Hydrastus, the use of in epithelioma of the lip, 58 
Hydrochlorate, cocoaine, the anesthetic use of, 58 
Hypericum, the use of in shock, . . 74 

Infiltration of glands in epithelioma, . 56 

Inheritance of epithelioma, . . 47 

Involution of epithelial structures, relation of 

to their pathology, . . - 43 

Iodide of calcarea, the use of in epithelioma, 58 
Iodoform, the use of in dressing wounds, 70, 74,106 
Iodoform gauze of Prof. Billroth, . 70, 106 

Irritation, a cause of epithelioma of the gums, 64 
Jaegar's method of gaining access to the mouth, 99 
Jaw, contraction of the muscles of, after its 

excision, . . . .71 

Kocher's, Prof., amputation of the tongue, 

100, 102, 105 
Labial glands, situation of, . . 41 

Langenbeck's, V., the operation of, . 96 

Leucoplakia, relation of to epithelioma of the 

tongue, . . . . 78 

Life, average duration of, in epithelioma of 

the lip, ... 55 

Life, prolongation of, by operating for epithe- 
lioma of the tongue,. . . 93 
Ligature, the animal, in hemorrhage, . 74 
Limiting membrane, absence of in epithelioma, 39 
Lingual arteries, the ligation of, . 100, 102 
" glands, the situation of, . . 41 



114 INDEX. 

Lips, adjusting the severed, . . 74 

" destruction of, caused by epithelioma, 50, 53 
" early stages of epithelioma of the, . 50 

" epithelioma of the, . . 49 

" epithelioma of the, confounded with 
other diseases, . . . 51 

Lips, epithelioma of the, return of after operation, 56 
" epithelioma of the. treatment of, with 

caustic-. .... 66 

" epithelioma of the, local treatment of, 58 

Listerian Gauze, use of in Kocher's operation, 104 
Liston's Bone Forceps, . . 6 7. 76 

" Xeedles in Billroth's Operation, . 104 
Lizars, Mr. John, operation of, . 73 

Lymphatics, invaded in epithelioma of the 

tongue, . . . . 85, 87 

Lymphatics, early involvement of in syphilis, S9 
" causes of invasion of the, . 39 

Lymphatic glands, necessity of removing, in 

amputation of the tongue, . 95, 106 

Lymphatic glands, easily reached by Kocher's 

operation, . . . . 105 

Lupus, the corium the seat of, . 53 

" resemblance of to epithelioma, . 53 

Malignancy, causes of, ... 30 

Malignancy, histological marks of superlative, 34 
Malignant neoplasms, use of iodoform for, 106 

Marasmus, causes of in epithelioma of the 

tongue, . . . ^5 



IT^DEX. 115 

Maxillary bone, changes induced by epitheli- 
oma of the, ... 54 
Maxillary bone, cannot be converted in epithe- 
lial tissue, .... 62 
Maxillary bone, removal of the superior, 68, 72 
Medicines, how long shall they be exhibited 

before operating, . . . 91 
Medicines, the position of, in the treatment of 

epithelioma of the tongue, . . 93 
Mercury, bi-chloride, as an antiseptic, . 60, 105 
Microscope, the use of, to differentiate neo- 
plasms, . . . .52 

Membrana propria, . . . 15 
Men, causes of the more frequent development 

of epithelioma in, . . 79 

Men, epithelioma of the tongue in, . 79 

Mortality, after amputation of the tongue, 94 

Mouth, development of the, . . 13 

" epithelioma of the, . . 29 

" minute anatomy of epithelioma of the, 38 

" epithelium of the, . . . 12 

" origin of epithelium of the, . 33 

" mucous glands of the, . . 21 

" and pharynx, communication between the, 13 

" the primitive, . . . 12 

" simplest form of, . . . 14 

Mucous glands, epithelium of the, . 75 

" membrane, . . . 20 

" origin of buccal, . . 21 



116 IXDEX. 

Mucous, relation of columnar cells to the secre- 
tion of, .... 20 
Mueigen. . . . . 20 
Neoplasms, origin of in peculiar poisons, . 32 
Xitrite of silver, the use of in epithelioma. 66 
Xornial methods, the prototype of abnormal 

methods, .... -48 

Xucleus, the situation of in columnar cells, 20 

Xuhn, the glands of, . .' . 22 

Operations, effect of upon life, . . 66 

" for epithelioma of the lip, . 58 

" " " of the palate, . 75 
" " " of the tongue, 92, 95 
" infra maxillary, for amputating 
the tongue, .... 100 

Operations, the simplest will give the best re- 
sults, .... 96 

Orientals, causes of immunity of the. from 

epithelioma, . . . .54 

Pabulum, extraction of from the blood, 31 
Paget'Sj Sir James, disease of the nipples, com- 
parison between, and leucoplakia, . 88 
Pains, in epithelioma of the tongue, . 87 
Palate, division of the. . . . 73 
" deformity resulting from, . 76 
" plates of the superior maxillary bone, 

removal of the, . . . 76 



INDEX. 117 

Palate, epithelial covering of the, . 19 

" epithelioma of the, . . 75 

" " histology of, . 75 

" " treatment of, * . 75 

Papilla? of the tongue, . . 19 

Parotid gland, cells of the, . . 24 

Permanganate of potassium wash, . 70, 77 

Pharynx, origin of the, . . . 13 

" packing of the, in tracheotomy, 101 

Physical decay, a process of equilibration, 43 

Phytolacca, the use of, in epithelioma of the 

gum, ..... 65 
Phytolacca, the use of, in epithelioma of the lip, 58 

Ranunculus, the use of in epithelioma of the 

gums, .... 64 
Ranunculus, the use of in epithelioma of the 

lip, ..... 58 
Recurrent neoplasms, the essentials of operat- 
ing upon, . . . . 77 
Roux's amputation of the tongue, . . 96 
Saliva, . . . . . 24 
Salivary cells, multiplication of the, . 25 
" glands, epithelioma of the, .. 36 
" glandular epithelium, regeneration of, 24 
'• glands, during the senile period, 44 
Schwimmer, Prof., on leucoplakia, . 78 
Senile period, effect of, upon the glands of di- 
gestion, . . . .44 



118 INDEX. 

Septicaemia, danger of, increased by dividing 

the maxilla, ... 96 
Septic matter, infiltration of the lungs with, 96 
Shock, Hypericum in, ... 74 
Smoking, as an etiological factor, . 54 
Smoke, products of the dry distillation of, 80 
Spray, the use of the carbolic acid, in amputa- 
tion of the tongue, . . 105 
Stimulants, effect of upon the development of 

epithelioma, .... 80 

Sublimated cotton, the use of, . 70, 106 

Sub-lingual glands, the mucous cells of the, 23 

Sub-maxillary glands, the mucous cells of the, 23 
Sutures, the time for removing, after operating 

on the lip, .... 60 
Syphilis, complicates the diagnosis of epitheli- 
oma, .... 89 
Syphilis, relation of, to the development of 

epithelioma, . . . .81 

Syphilitic, lesions the floor of, . 89 

Tampon, Trendelenburgh's, . . 67 

" Taste buds " of the tongue, . . 19 

Tobacco, effect of, upon the development of 

epithelioma, .... 54, 80 
Tongue, the age at which epithelioma develops, 79 
" amputation of the, . . 95 

" amputation of the, dangers to antic- 
ipate from, . . . .95 



INDEX. 119 

Tongue, causes of epithelioma of the, . 86 

" characteristics of epithelioma of the, 85 

" chronic character of epithelioma of the, 88 
" development of epithelioma of the, in 

men, . . . . .79 

" diagnosis of epithelioma of the, 88, 90 

" epithelioma of the, . . 77 

" '" " originating in a 

fissure, . . . . 85 

Tongue, epithelioma of the, originating in leu- 

coplakia, .... 85 
Tongue, local character of epithelioma of the, 84 
" malignancy of epithelioma of the, 82 
mortality after amputation of the, 94 
" nodular form of epithelioma of the, 83 
" quiescent period of epithelioma of the, 84 
" removal of the, through the mouth, 96 
" removal of the, through an infra-max- 
illary incision, . . . 100 
Tongue, section of epithelioma of the, . 83 
" situation of epithelioma of the, 83 
" suspected epithelioma of the, . 94 
" treatment of epithelioma of the, 90 
Tracheotomy, advantage of, . . 106 
" a preliminary operation, . 100 

Ulcer, the bottom of an epitheliomatous, 51 

" characteristics of an epitheliomatous, . 50 

" edges of an epitheliomatous, . 49 



120 INDEX. 

Vital changes, origin of, . . . 48 

Waste cells, relation of to pathological forma- 
tions, .... 45 
Whip-cord, the use of in amputating the tongue, 99 
Whitehead's Mr., amputation of the tongue, 99 
Women, causes of their immunity from epithe- 
lioma, ..... 81 
Wounds, the dressing of, . . 60, 106 
" the use of the dry dressing for, . 70 
Zinc, paste of chloride of, after operating, 70 
Zinc, wash of chloride of after operating, 59, 70, 106 






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